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A    TEXT-BOOK 


MENTAL     DISEASES. 


A    TEXT-BOOK 


OF 


MENTAL    DISEASES: 


WITH  SPECIAL  REFERENCE  TO 


THE  PATHOLOGICAL  ASPECTS  OF  C^SAl^ITY. 


BY 

W.    BEVAN    LEWIS, 

L.R.C.P.  (LoND.),  M.R.C.S.  (Eng.), 

MEDICAL  DIRECTOR,  WEST  RIDING  ASYLUM,  WAKEFIELD, 
LECTURER  ON  MENTAL  DISEASES    AT  THE  YORKSHIRE  COLLEGE. 


WITH   ILLUSTRATIONS   IN    THE    TEXT,    CHARTS,  AND 
EIGHTEEN  LITHOGRAPHED   PLATES. 


PHILADELPHIA: 

P.    BLAKISTON,    SON    &    COMPAN-Y, 

1012    WALNUT    STREET. 

1890. 


SIR  JAMES   CRICHTON-BROWNE, 

M.D.,    LL.D.,    F.R.SS.    (lOND.    AND   EDIN.), 
lOED  CHANCBtlOE'S  VISITOR  IN  LUNACY,  LATE  MEDICAL  DIRECTOK  OF  THE  WEST  BIDING  ASTLUK 

AT  WAKEFIELD, 

5n   B&miratfon   of 

THE  VIGOROUS  INTELLECT,    COMMANDING   ELOQUENCE,    AND   UNTIRING    ENERGY 

BROUGHT  TO  BEAR  ON  THE  SCIENTIFIC  ASPECTS  OF 

PSYCHOLOGICAL   MEDICINE 

DURING  HIS  DIRECTORATE   OF  THE   WEST   RIDING   ASYLUM  ; 

anJ)  in  Ikeen  appreciation  of 

HIS    WIDE-SPREAD     SYMPATHIES    AND     GENEROUS    IMPULSES, 

ZTbis  moth  is  DeOicateD 

BT 

THE  AUTHOR. 


PEEFACE. 


In  writing  a  new  Treatise  on  Mental  Diseases,  I  have  not  been 
blind  to  the  wealth  of  available  literature  in  this  department, 
nor  to  the  claims  upon  the  Student's  attention  of  such  works 
as  the  classical  Manual  of  Bucknill  &  Tuke,  the  English 
translation  of  Griesinger's  Treatise,  and  the  admirable  Lectures 
of  Dr.  Blandford,  nor  again  to  the  more  recent  additions  to 
Dr.  Bristowe's  Clinical  Medicine,  and  the  works  of  Drs. 
Sankey,  Clouston,  and  Savage. 

It  has,  however,  been  my  special  object  to  present  a  resumS 
of  our  knowledge  of  the  structure  and  connections  of  the 
cerebro-spinal  nervous  system,  of  the  architecture  of  the  cerebral 
hemispheres,  and  more  especially  of  the  cortical  envelope  as 
the  essential  organ — the  material  substratum — of  Mind ;  and  to 
afford  a  concise  account  of  the  morbid  changes  found  in  the 
brain  of  the  insane,  as  viewed  in  the  light  of  recent  research. 

It  appears  to  me  that  a  disproportionate  amount  of  attention 
has  been  paid  in  former  text-books  to  the  clinical  aspects  of 
Insanity,  and  it  is  hoped  that  this  attempt  to  deal  more  fuUy 
with  the  organisation  of  the  material  substratum  of  mind,  and 
with  the  evidences  of  morbid  change  to  which  it  is  prone,  will 
not  prove  unwelcome  to  the  Student  of  Mental  Disease. 

In  the  Anatomical  Section,  I  have  endeavoured  to  comprise 
such  information  as  shall  prove  of  utility  to  a  more  thorough 
conception  of  the  ground-plan  and  superstructure  of  the  nervous 
system ;  and  it  will  be  at  once  evident  that  special  emphasis 
has  been  advisedly  bestowed  upon  the  cortical  envelope — the 
structure,  nature,  and  autonomy  of  the  nerve-cell. 


VUl  PREFACE. 

The  Clinical  Section  comprises  statistics  based  upon  an 
analysis  of  4,000  cases  of  Insanity  in  both  sexes,  treated  at  the 
West  Riding  Asylum. 

In  the  Pathological  Section,  I  have  endeavoured  to  do  justice 
to  certain  morbid  processes,  which  appear  to  me  to  be  of 
paramount  importance  in  the  history  of  Insanity;  and  more 
particularly  would  I  here  allude  to  the  functions  of  the  Lymph- 
connective  system  of  the  Brain,  and  the  life-history  of  the 
"  Scavenger-cell." 

To  my  publishers  I  would  desire  to  express  my  acknowledg- 
ments for  the  consideration  uniformly  received  at  their  hands, 
despite  the  delay  which  has  unavoidably  occurred — for  the 
liberal  supply  of  illustrations,  so  essential  to  the  success  of  a 
work  of  this  description,  and  for  the  special  care  taken  in 
their  production.  I  can  add  my  testimony  to  the  admirable 
faithfulness  with  which  my  drawings  have  been  reproduced  by 
Mr.  Danielsson. 

I  have  also  to  express  my  obligations  to  my  colleague, 
Mr.  St.  John  Bullen,  for  reference  to  a  compilation  of  Statistics 
from  the  Pathological  Records  of  this  Asylum,  and  for  material 
assistance  in  the  revision  of  the  proof-sheets. 

West  Riding  Asylum, 
Wakefield,  November,  1889. 


GENEEAL    CONTENTS. 


PART  I.— ANATOMICAL  AND  HISTOLOGICAL  SECTION. 

The  Spinal  Cord — The  Medulla  Oblongata — The  Mesencephalon — The  Prosen- 
cephalon—  The  Encephalon  as  a  whole  —  The  Cerebral  Cortex  —  Cortical 
Lamination, Pages  1-114- 


THE   SPINAL   CORD. 

The  Cerebro-Spinal  Axis— The  Central  Grey  Matter— The  White  MeduUated 
Columns — Transverse  Section  of  Cord — Substantia  Gelatinosa  and  Vesicular 
Columns — Caput  Cornu— Sacral  Nucleus  of  Stilling — Anterior  Cornu — Inter- 
medio-lateral  Tract  of  Clarke — Formatio  Reticularis — Conducting  and  Com- 
missural Tracts — Direct  Pyramidal  Tract — Crossed  or  Lateral  Pyramidal 
Tract — Posterior  Median  Column — Postero-lateral  Columns — Direct  Cerebellar 
Tract — Cowers'  Antero-lateral  Ascending  Tract — Anterior  Radicular  Zone 
and  Lateral  Limiting  Layer, Pages  1-8 

THE  MEDULLA  OBLONGATA. 

Region  of  the  Calamus  Scriptorius — Clavate  and  Cuneate  Nuclei — Solitary  Fasci- 
culus— Nucleus  of  Fasciculus  Teres — Floor  of  Fourth  Ventricle  (lower  half) — 
Hypoglossal  and  Vago-accessory  Nuclei — Ascending  Root  of  Fifth  Nerve — 
Motor,  Mixed  and  Sensory  Systems— Restiform  Tract — Dentate  Nucleus- 
Inner  and  Outer  Divisions  of  Cerebellar  Peduncles — Roof  Nuclei  of  StilUng — 
Arcuate  Fasciculi— Fillet — Nucleus  of  Lateral  Column — Inferior  Olivary  Body 
— Internal  and  External  Accessory  Olives— Corpus  Trapezoides — Origin  of 
Hypoglossal  Nerve — Mixed  Lateral  System — Spinal  Accessory,  Vagus  and 
Glosso-Pharyngeal — Upper  Half  of  Medulla — Abducens,  Facial  and  Acoustic 
Nuclei — Superior  and  Inferior  Olivary — Inferior  Facial  Nucleus — Nuclei 
of  Acoustic  Nerve  —  Sound-rod  of  Bergmann  —  Acoustic  Striae  —  Facial 
Genu — Ascending  Trigeminal  Root — Abducens  Facialis — Superior  Olivary 
Body — Lemniscus  or  Fillet— Upper  Angle  of  Fourth  Ventricle — Posterior 
Longitudinal  Fasciculus  —  Nuclei  and  Root-fibres  of  Trigeminal  —  Locus 
Cceruleus — Nuclei  of  Oculo-Motor  and  Trochlearis— Root-fibres  of  Fourth 
Nerve, Pages  8-27 

THE  MESENCEPHALON. 

Advance  in  Complexity  —  Tegmental  and  Crustal  Tracts  —  Internal  Capsule  — 
Corpora  Quadrigemina  and  Thalami  —  Locus  Niger  —  Knee  of  Capsule  — 
Posterior  Perforated  Space — Basal  Aspect  of  Mesencephalon — Tsnia  Pontis — 


X  CONTENTS. 

Corpora  Alhicantia — Infundibulum  and  Pituitary  Body — Conducting  Tracts 
of  CrustJi— Fundamental,  Mixed,  and  Accessory  Systems — Cortical  Termination 
of  Tracts — Relationships  to  Motor  Cells  of  Cortex — Termini  of  Sensory 
Columns  of  Cord  —  Radiations  of  Gratiolet  —  Sensory  Peduncular  Tract  — 
Constitution  of  Internal  Capsule — Ansa  Peduncularis — Substantia  Nigra — 
Fillet  or  Lemniscus  —  Pineal  Body  —  Posterior  Commissure  —  Aqueduct  — 
Tegmental  Structures— Superior  Bigeminal  Body  or  Nates — Its  Brachia  and 
Stratum  Lemnisci  —  Red  Nucleus  —  Upper  Cerebellar  Peduncle — Posterior 
Longitudinal  Fasciculus — Substantia  Nigra — Relationships  and  Connections 
of  Tcgment  and  Crusta, Pages  27-41 

THE  THALAMENCEPHALON. 

External  Conformation — Inner  and  Outer  Face  of  Optic  Thalami — Subthalamic 
Body — Thalamic  Peduncles — Fimbria  of  Fornix — Pillars  of  Fornix — Cortical 
Connections  of  Optic  Thalami  —  Lamina  Medullaris  of  Burdach  —  Centre 
Median  of  Luys — Stratum  Zonale — Anterior  Tubercle  of  Thalamus — Pineal 
Body  and  its  Connections — Fasciculus  Retroflexus — Posterior  Commissure — 
Corpora  Geniculata, Pages  41-49 

THE    PROSENCEPHALON. 

Configuration  of  Fore-brain — Lenticular  and  Caudate  Nuclei — Lenticular  Axis  of 
Revolution — Relationships  of  the  Lenticular  and  Caudate  Nuclei — Head  of 
Caudate  Nucleus  —  Tail  of  Caudate  Nucleus  —  Amygdaloid  Nucleus  —  The 
Surcingle  —  Loop-like  Disposition  of  Ganglia  —  Stria  Terminalis  or  Taenia 
Semicircularis — Olfactory  Area — External  Conformation  of  the  Lenticular 
Nucleus — The  Claustrum  and  Insula — Globus  Pallidus — Lamina  MeduUares 
of  Lenticular  Nucleus, .      Pages  49-55 

THE    ENCEPHALON  AS   A  WHOLE. 

Comparative  and  Embryological  —  The  Neural  Tube  in  Amphioxus  and  in  the 
Lamprey — The  Brain  in  Fishes  and  Ampliibia — The  Five  Vesicles  of  the 
Neural  Tube — The  Cerebral  Hemispheres  in  Fishes — Hypoaria — Predomin- 
ance of  Optic  Lobes  in  Insects — The  Reptilian  Brain — The  Brain  in  Birds — 
Development  of  Neural  Canal — Vesicles  of  the  Fore-brain — Olfactory  Lobe — 
Foramen  of  Monro — Ganglia  of  Fore-brain — Pituitary  Body — The  Neuro- 
enteric  Canal — Vesicle  of  ]\Iid-brain — Formation  of  Quadrigeminal  Bodies 
and  Crura — The  Iter — Vesicle  of  Hind-brain — The  Cranial  Flexures — Forma- 
tion of  Fissures, Pages  55-60 

THE  CEREBRAL  CORTEX. 

Methods  of  Enquiry — The  Grey  Matter  the  Tissue  of  Mind — Histological  Elements 
of  the  Cortex — Nerve-cells — Angular  Cell — Its  Development  in  the  Pig,  Sheep, 
Rat,  and  Pvabbit — P^elatively  Large  Nucleus — Granule  Cell — Pyramidal  Cell 
— Apex,  Basal,  and  Secondary  Processes — The  Motor  Cell — Giant  Pyramids 
of  Betz — Primary  and  Secondarj'  Branches — Type  of  Cell  in  Man,  &c. — 
Inflated  or  Irregularly  Globose  Cell — Its  Restricted  Distribution  in  Rodents 


CONTENTS.  XI 

— The  Spindle  Cell  —  CLaustral  Formation  —  Nerve-fibres  of  Cortex  —  The 
Primitive  Fibril — Non-Medullated  Fibres — Axis-cylinder  Process — Medul- 
lated  Nerve-fibre— Myelin  Sheath  —  Keratoid  Sheath  —  Fromann's  Lines — 
Lantermann's  Dissepiments — Centric  and  Peripheric  Fibres — Staining  of  Axis- 
cylinder — Arteries  of  the  Cortex — Intima — Tunica  Media — Tunica  Adventitia 
— Perivascular  Channel  of  His — The  Capillaries  of  the  Cortex — Stigmata  and 
Stomata — The  Veins  of  the  Cortex — The  Connective  Matrix  or  Neuroglia — 
Local  Varieties — Cellular  Elements  of  Neuroglia — Lymphatic  System  of  the 
Brain — The  Perivascular  Channels  and  Lymph  Channels  Proper — Epicerebral 
Space — Pericellular  Sacs — Cells  of  Adventitial  Tunic — A  Description  of  the 
Lymph  System— The  Lymph -connective  Elements  or  Scavenger-cells — Vascular 
Process  of  Scavenger-cell — Role  of  Spider-  or  Scavenger-cells,    .      Pages  60-85 

CORTICAL   LAMINATION. 

Laminated  Structure  of  Cortex— Cerebral  Hemisphere  in  the  Rodent — Eight 
Types  of  Cortex — Transition  Regions  in  Man — Distribution  of  the  several 
Types — Upper  Limbic  Type — Modified  Upper  Limbic  Type — Outer  Olfactory 
Type— Inner  Olfactory  Type — Modified  Lower  Limbic  Type — Extra-limbic 
Type — Type  of  Cornu  Ammonis— Type  of  Olfactory  Bulb — Diversities  of 
Cortical  Lamination — Regional  Distribution  of  Ganglionic  Cells  in  Cortex — 
The  Clustered  and  Solitary  Arrangements — Distribution  in  the  Pig,  Sheep, 
Cat,  Ape,  &c. — Significance  of  Fissures  and  Sulci — Fissures  defining  Distinct 
Cortical  Types — Contrasts  between  Brain  of  Man  and  Lower  Mammals — 
Lamination  of  Motor  Area  in  Man  —  Five-laminated  Cortex — Histological 
Structure  of  the  Several  Layers  of  Motor  Cortex — Distribution  of  Motor-cell 
Groups  —  Transition-realms  of  Cortex — Specialised  Areas — Acquirement  of 
Structural  Variations — Significance  of  Cell-groupings — Comparative  Size  of 
Brain-Cells — The  Nucleus  of  the  Nerve-cell  and  its  R6le — Electrical  Excita- 
bility of  Cortex — Latent  Period  of  Stimulation  and  the  Summation  of  Stimuli 
— Conditions  Affecting  Excitability — Functional  Equivalence  of  Cortex — 
Faradic  Stimulation  of  Cortex- — Extra-polar  Conduction  —  Conduction  to 
Lower  Centres — Proximity  of  Psycho-motor  Centres,         .         .    Pages  85-114 


PART    II.— CLINICAL    SECTION. 

States  of  Depression — States  of  Exaltation — Fulminating  Psychoses — States  of 
Mental  Enfeeblement  —  Recurrent  Insanity  —  Epileptic  Insanity  —  General 
Paralysis  of  the  Insane  —  Alcoholic  Insanity  —  Insanity  at  the  Periods  of 
Puberty  and  Adolescence  —  At  the  Puerperal  Period  —  At  the  Climacteric 
Epoch — Senile  Insanity, Pages  115-431 


STATES   OF   DEPRESSION. 

Mental  Depression  Defined — Decline  of  Object-consciousness — Rise  of  Subject- 
consciousness —  Muscular  Element  of  Thought  —  Failure  in  the  Relational 
Element  of  Mind  —  Sense  of    Environmental   Resistance  —  Reductions   to 


XU  CONTENTS. 

Automatic  Levels — Sense  of  Effort — Restricted  Volition — Enfeebled  llepre* 
sentativeness  —  Transformations  of  Identity  —  The  Physiological  Aspect  — 
Defective  Circulation  —  Nutritional  Impairment  —  Explosive  Neuroses  — 
Hunger  of  the  Brain-cell  —  Painful  and  Pleasurable  Mental  States  —  Re- 
action-time in  Melancholia  —  Degrees  of  Mental  Depression  —  Clinical 
Varieties  of  Melancholia  —  Simple  Melancholia  —  Delusional  Melancholia  — 
Hypochondriacal  Melancholia  —  Melancholia  Agitans  —  States  of  Mental 
Stupor — Stupor  and  Hypnotism — Acute  Dementia,         .         .  Pages  115-150 

STATES   OF  STUPOR. 

Stupor  and  Dementia — Etiology  of  Stuporose  States — Stupor  and  Hypnotism — 
Stuporose  Melancholia — Acute  Primary  Dementia,    .         .         .  Pages  150-162 

STATES   OF   EXALTATION. 

Maniacal  Reductions  —  Failure  of  Attention  —  Enfeebled  Synthesis  —  Transient 
Delusive  States — Exalted  Sense  of  Freedom — Impulsive  Conduct — Nocturnal 
Crises — Seclusion  Fosters  Hallucination — Sexual  Illusions — Stadium  Melan- 
cholicum  —  Enfeebled  Imagination  —  Bodily  Symptoms  —  Periodicity  of 
Maniacal  Phenomena — Acute  Delirious  Mania,        .         .         .  Pages  162-176 


FULMINATING   PSYCHOSES. 

Uniform  and  Partial  Denudations — Defective  Control — The  Neurotic  and  Criminal 
Subject — Nature  of  Impulsive  Insanity^Insane  Homicidal  Impulse — Exist- 
ence of  Aura — Epigastric  Aura — Uncovering  of  the  Brute  Instincts — Relief  of 
Mental  Tension — Illustrative  Cases — Suicide  in  Homicidal  Subjects — Etiology 
— Effect  of  Physiological  Cycles — Epilepsy — Masked  Epilepsy — Alcohol  and 
Impulsive  Insanity — The  Mimetic  Tendency — Suicidal  Impulse,  Pages  176-188 

STATES   OF   MENTAL  ENFEEBLEMENT. 

Mental  Deprivation  in  Contradistinction  to  Developmental  Arrest — Persistent 
Enfeeblement — Chronic  Residue  of  Asylum  Communities — Recoverability  of 
Maniacal  and  Melancholic  Forms — Consecutive  Dementia — Delusional  In- 
sanity— Genesis  of  Monomaniacal  States — Environmental  Resistance — Trans- 
formation Completed — Mystic  Symbolism — Illustrative  Cases  of  Delusional 
Insanity — Monomania  of  Pride  (/.  0.,  E.  T.) — Religious  Monomania  (J.  B.) — 
^lonomania  of  Persecution  (E.  C), Pages  188-200 

RECURRENT    INSANITY. 

Definition — Establishment  of  Labile  Equilibrium — Prevalence  at  Sexual  Deca- 
dence— Heredity — Influence  of  Neurotic  Heritage  and  of  Ancestral  Intem- 
perance— Atavism — P»-ccurreuce  in  the  Congenitally  Defective  Subject — Morbid 
Excitement  and  the  Moral  Imbecile — Alternations  of  Excitement  and  Stupor — 
Hysteria  and  Menstrual  Irregularity — Eroticism  {A.  S.,  M.A.M.) — Recurrence 
in  Adolescence  (J/.  C.    )r.)— Recurrence  at  the  Climacteric  {H.  0.) — at  the 


CONTENTS.  XUl 

Senile  Epoch  (/.  (S".) — in  Puerperal  Subjects  {M.  B.) — in  Traumatic  Insanity 
(B.  L.) — Morbid  Impulsiveness — Hallucination  and  Delusion  (/.  £.)— Pro<r- 
nosis — Treatment,      .........  Pages  201-220 

EPILEPTIC    INSANITY. 

Definition  —  Epileptic  Neurosis  —  Immediate  and  Remote  Results  of  Epileptic 
Discharge — Diffusion-currents  —  Nascent  Nerve-tracts — Discharge  from  Sen- 
sory Areas — The  Aura  in  Sensory  Epilepsies — Epileptic  Amaurosis,  Hemian- 
opsia and  Hemiansesthesia — Champing  Movements — Pre-paroxysmal  Stage — 
Tremonitory  Stage — Special  Sense  Auras — Vasomotor  and  Visceral  Aurae — 
The  Epileptic  Paroxysm — Grand  and  Petit  Mai — Post-paroxysmal  Period — 
Post-epileptic  Automatism  —  Case  of  E.  C.  —  Status  Epilepticus  —  Inter- 
paroxysmal  Stage — Epileptic  Hypochondriasis,  Automatism  and  Impulsiveness 
— Medico-legal  Relationships — Impulse — Delusion — Malingering — Reg.  v. 
Taylor — Treatment  of  Epileptic  Insanity, Pages  221-250 

GENERAL  PARALYSIS   OF   THE   INSANE. 

Prodromata — Egoism — Early  Moral  Perversion — Failure  of  Re-representative 
States — Enfeebled  Attention — Transient  Amnesia — Vasomotor  Derangements 
— Early  Paresis — Second  Stage — Delusions  of  the  Paralytic  and  Monomaniac 
— Vanity  and  Decorative  Propensities — Sexual  Perversions — Facial  Expression 
— Articulatory  Impairment — Cerebral  Seizures — Syncope — Epilepsy  (/.  F.) — 
Unilateral  Twitching  (/.  S.) — Epileptiform  Attacks — Conjugate  Deviation — 
Case  of  H.  P. — Apoplectiform  Seizures — Monoplegice— Hemiplegite — Spastic 
and  Paralytic  Myosis — Mydriasis  and  Amaurosis — Reflex  and  Associative 
Iridoplegia — Statistical  Tables — Consensual  Movements— Reflex  Dilatation — 
Reaction-time — Spinal  Symptoms  (if.  J.  R.) — Deep  Reflexes— Tabetic  Gait 
[H.  U.) — Incontinence  and  Retention — Atrophy  of  Vesical  Muscle— The  Blood 
in  General  Paralysis, Pages  250-288 

ALCOHOLIC    INSANITY. 

Alcoholism  and  Age — Susceptibility  at  Certain  Developmental  Phases — Adolescent 
Period  [F.  S.) — Prevalence  of  Impulse — Influence  of  Sex,  Heredity,  Epilepsy, 
Cranial  Injury,  Ancestral  Intemperance — Anomalies  of  Systemic  and  Visceral 
Sensation — Aural  Hallucinations  {J.  J^.) — Delusions  of  Suspicion — Optimistic 
Delusions — Clinical  Forms  of  Alcoholism — Mania  a  Potu — Amblyopia — 
Cutaneous  Ansesthesia — Relapses — Case  of  IF.  W. — Homicidal  Impulse  (G.  S.) 
— Chronic  Alcoholism — Physiological  Effects  of  Alcohol — Evolutionary  Period 
— Mental,  Sensorial,  and  Motorial  Symptoms  (/.  J'^.) — Amnesic  Forms  (/.  F.) 
—Conditions  of  Mental  Revivability  {31.  H.  i.)— Delusional  Forms  (T.  S.) 
— Instances  of  ' '  Environmental  Resistance  " — Visceral  Ilhisions — The  Epi- 
gastric Voice — Various  Illusory  States  {E.  A.  F.) — Evolution  of  Psychical 
Phenomena — The  Nervous  Discharge — Hallucinations  as  Detennining  JNIorbid 
Ideation  —  Augmented  Specific  Resistance  —  Sensory  Anomalies  —  Motor 
Enfeeblement  (/.  R. )  —  Twitchings,  Tremors,  Stolidity  —  Reaction-time  in 
Alcoholism  —  Muscular  Spasms  and  Cramps  —  Oculo-motor  Immunity  — 
Nystagmus— Epileptiform  Attacks— Hemiplegias  [T.  P.  and  J.  C.)— Classifica- 
tion,   Pages  288-333 


XXV  CONTENTS. 


INSANITY  AT  THE  PERIODS  OF  PUBERTY  AND  ADOLESCENCE. 

Evolution  of  Puberty  and  Adolescence — Pubescence  as  Distinguished  from  Adol- 
escence —Antagonism  of  Growth  and  Development — Excessive  Metabolism  of 
Infancy — Acquibitiveness  and  Mimetic  Characters  of  Childhood — Initiative 
Tendencies  of  Adolescence — Pubescent  Insanity  in  the  Female— Delusions 
and  Hallucinations — Relapses  at  Menstrual  Periods — Hysteric  Type  of  Mania 
— Stupor  Coincident  with  Menstrual  Derangement  — Case  of  F.  ^Y. — The 
Blood  m  Stuporose  States— Case  of  M.  A.  II. — Etiology— Ancestral  Influence 
— Periods  of  Susceptibility  —  Statistics  of  Hereditary  Factors  —  Ovarian 
Derangements  and  Pubescent  Insanity  {A.  H.) — Amenorrhaal  and  Ana;mic 
States — Influence  of  the  Environmental  Factors— Percentage  of  Hiemoglobin 
in  Cases  of  Stupor — Pubescent  Insanity  in  the  Male — Sexual  Divergence — 
Symptoms  of  Pubescent  Insanity — Modified  Forms  (/.  M.) — Masturbatic  and 
Uncomplicated  Form  of  Pubescent  Insanity — Etiology — The  Moral  Imbecile, 

Pages  33-4-364 


INSANITY  AT  THE  PUERPERAL  PERIOD. 

Symptoms — Predominance  of  Mania — Intensity  of  the  Morbid  Process — Obtrusive 
Sexual  Element  —  Hallucinations  —  Delusions  of  Suspicion  —  Prevalence  of 
Suicidal  Feelings  —  Etiology  —  Susceptibility  of  the  Puerperal  Period  — 
Illegitimacy  and  Puerperal  Insanity — Frequency  in  Primiparffi — Condition  of 
the  Blood — Diminution  of  Haemoglobin — Prognosis — Treatment — Insanity  of 
Pregnancy — Relatively  Infrequent — Primipara;  Show  no  Special  Liability  — 
Symptoms— Recoveries, Pages  365-376 

INSANITY  AT  THE  PERIOD  OF  LACTATION. 

Risks  attendant  upon  Lactation  —  Period  of  Uterine  Involution  —  Period  of 
Mammary  Excitation— Symptoms — Depressing  Delusions— Impulsive  Nature 
(M.  W.) — Suicide  [M.  D.) — Case  oi  E.  E.  C. — Intensity  of  Maniacal  Excitement 
—  Sexual  Perversions  —  Hallucinations  —  Etiology  —  Exhaustion  and  the 
Sequelae  of  Labour  —  Protracted  Uterine  Involution  —  Lactation  during 
Profound  Antemia— Hyperlactation — Qualifications  of  the  Nursing  Mother — 
Period  for  Weaning — Prognosis — Treatment,     .         .         .  Pages  376-392 


INSANITY  AT  THE  CLIMACTERIC  EPOCH. 

Symptoms — A  Subacute  Delusional  Melancholia  —  Suicidal  Tendency  (S.  H.) — 
Nymphomania  [A.  A.) — Etiology — Incidence  of  Insanity  at  dififerent  ages  in 
4085  cases — Influence  of  the  Climacteric — The  Psychological  Transformations 
of  this  Epoch  —  Instinctive  Actions  —  The  ^^  Time-element"  in  Prognosis  — 
Alcoholism  and  the  Climacteric — Treatment,     .         .        .  Pages  392-405 


SENILE  INSANITY. 

Mental  derangements  Incident  to  Senility — Senile  !Mania — Senile  Melancholia — 
Chronic  Cerebral  Atrophy] —  Senile  Convulsions  —  Senile  Epilepsy  —  Senile 
Dementia — Inheritance  as  a  Factor  in  Senile  Insanities — Exhaustive  Brain- 


COXTENTS.  XV 

work  —  Alcohol  and   Senility  —  Case  of   T.    O. —  Onset  and  Prodromata  — 

Character  of  the  Senile  Reductions — Senile  Hypochondriasis  (/.  A.) — Senile 
Atrophy  and  Tlirombosis  (/.  B.) — Acute  Senile  Melancholia  and  Syncopal 
Attacks  (//.  D.) — Partial  Exaltation  in  Senile  Insanity — Delusional  Per- 
versions of  the  Monomaniac  and  Senile  Subject  Contrasted — Senile  Amnesia — 
Cases  of  Senile  Insanity  [M.  H.  and  A[.  ilf. )— Elimination  of  Urea  in  Chronic 
Cerebral  Atrophy  and  Premature  Senility — A  Local  Manifestation  of  Chronic 
Bright's  Disease, Pages  405-431 


PART  III.— PATHOLOGICAL  SECTION. 

Morbid  Condition  of  Cranial  Bones — Investing  Membranes — Brain-Substance — 
Histological  Elements  of  Cortex  —  Forms  of  Tissue  Degradation  ■ —  Patho- 
logical Anatomy  of  General  Paralysis,  of  Epilepsy,  and  of  Chronic  Alco- 
holism,         Pages  432-541 


GENERAL  PATHOLOGY  AND  MORBID  ANATOMY. 

The  Cranium — Dura  Mater — Pia- arachnoid — Arachnoid  Haemorrhage — Adherent 
Pia — Vascular  Apparatus — Congestion — Inflammation — Softening — Atrophy 
— Miliary  Sclerosis — Colloid  Degeneration — Granular  Disintegration  of  Nerve- 
cells — Pigmentary  or  Fuscous  Degeneration — -Developmental  Arrest  of  Nerve- 
cells — Vacuolation  of  Cell-protoplasm — Vacuolation  of  Nucleus — Destruction 
of  Intra-cortical  Nerve-fibre  plexus — Tissue  Degradation  from  Over-strain — 
Tissue  Degradation  from  Active  Morbid  Processes— Tissue  Degi-adation  from 
Disuse — General  Summary, Pages  432-493 

PATHOLOGICAL  ANATOMY  OF  GENERAL  PARALYSIS. 

The  Brain  and  Us  Membranes : — Early  Implication  of  Vascular  Tissues — Vital  and 
Mechanical  Effects  • —  Effects  on  Lymph- connective  System  —  Intracellular 
Digestion — B6le  of  Phagocytes,  or  Scavenger-cells — Character  of  Scavenger- 
element — Its  Vascular  Process — Fuscous  Degeneration  of  Nerve-cells — Three 
Stages  of  Morbid  Evolution  : — Inflammatory  Engorgement — Implication  of 
Pia-arachnoid — Nuclear  Proliferation  of  Adventitia — Paralysis  of  Arterial 
tunics  —  Diapedesis  —  Exudation —  Hsemorrhagic  Transudations  — Arachnoid 
Hfemorrhaoe — Second  Stage  : — Hypertrophy  of  Lymph  Connective  System — 
Fuscous  Change  and  Removal  of  Nerve-cells — Nature  of  the  Destructive 
Process — Early  Implication  of  Apex  Process — Third  Stage  : — Fibrillation  and 
Atrophy.  The  Spinal  Cord: — Spinal  Cases  in  Four  Groups — Evolution  of 
Pseudo-tabetic  aiid^Spastic  Paraplegic  Forms — Angio-Neuroses — Pathogenesis 
of  Transient  Tabetic  Forms — Changes  in  Vascular,  Connective,  and  Nervous 
Elements — System-implication  of  Lateral  Columns — Secondary  to  Cortical 
Lesions — Respects  Systematic  Barrier — Chronic  Parenchymatous  Myelitis — 
Dependent  on  Gradual  Degeneration  of  Cortical  Cells — Amyotrophic  Form — 
Degeneration  of  Cornual  Elements  in  Cervical  Associated  with  Descending 


X  vi  CONTENTS. 

Lateral  Sclerosis  in  Dorsi-lumbar  Regions — Combined  System  Implication  of 
Columns — Psfiulo-tabetic  Forms — Ataxic  Tabes — Loss  of  Knee-jerk — Anorexia 
— Flashing  Pains  and  Sensory  Symptoms — Genuine  Tabetic  Form  in  General 
Paralysis, Pages  493-521 

PATHOLOGY  OF   EPILEPSY. 

Modern  View  of  its  Nature  —  An  Impalpable  Trophic  Change  —  Objections  to 
Methods  of  Examination — Change  in  Elements  of  the  Second  Cortical  Layer — 
Fatty  Change  in  Nuclei  of  Nerve-cell — Common  also  to  Alcoholic  Insanity — 
Vacuolation  of  Nucleus — Ultimate  Break-down  of  Nerve-cell — Implication  of 
Motor-cells — Absence  of  Vascular  Implication— Functional  Endowments  of 
Nucleus — Resistance  of  Cell  to  Discharge — Nutritional  Rhythm — Significance 
of  Size  of  Cell  and  Nucleus — Primitive  Type  of  Nerve-cell — Degraded  Type  of 
Nerve-cell  —  Cell-conformation   as  indicative  of  a   Convulsive  Constitution, 

Pages  522-528 

PATHOLOGY  OF  CHRONIC  ALCOHOLISM. 

Morbid  Change  in  Cerebral  Vessels — Scavenger-cells  in  Outer  Zone  of  Cortex — 
Sclerosis  of  Outer  Zone — Amyloid  Bodies  beneath  Pia— Implication  of  Motor 
and  Spindle-cells  —  Significance  of  these  Changes  —  Deepest  Layers  more 
generally  Involved  —  Early  Vascular  Implication  —  Aneurysmal  Bulgings  — 
Atheromatous  and  Fatty  Change— Pigmentary  Degeneration  of  Motor-cells — 
Scavenger-elements  in  Spindle-layer  —  Degeneration  of  MeduUated  Nerve- 
fibre — Spinal  Lesions — Vascularity — Hypertrophy  of  Tunica  Muscularis  an 
Inconstant  Feature — Relationships  to  Chronic  Bright's  Disease— Sclerosis  of 
White  Columns  of  Cord — Spinal  Degenerations  in  Typical  Case — Implication 
of  Clarke's  Column — Immunity  from  Multiple  Neuritis — Neurotic  Heritage — 
Chronic  Endarteritis  —  Fatty  and  Sclerous  Tendency  —  The  Brain  of  the 
Criminal  Class — Exceptional  R,esemblance  to  General  Paralysis — Coincidence 
of  Grandiose  State  and  Delusions  of  Persecution — Inconstant  Vertical  Impli- 
cation of  Cord — Constitutional  State  that  of  Chronic  Bright's  Disease — 
Exceptional  Transition  to  General  Paralysis — Significance  of  Arterial  Changes 
— Affection  of  the  Visceral  System, Pages  528-541 


DESCRIPTION    OF    PLATES. 


.      PLATE  I. 
Illustrative  of  thk  "  Motor  Type  "  of  Cortex.  Page  60. 

The  section  taken  from  the  extra-limbic  area  of  rabbit's  brain,  near  the  frontal 
pole  of  hemisphere,      x  200. 

The  three  small  figures  represent  the  mesial,  basal,  and  coronal  aspect  re- 
spectively of  the  rabbit's  brain,  showing  distribution  of  the  various  types  of 
cortex. 

A.  Sub-frontal  and  sulj-parietal  segments  of  the  limbic  fissure.  B.  Gyrus 
hippocampi  or  lower  limbic  arc.  C.  Limbic  fissure.  D.  Occipital  pole. 
E.  Frontal  pole.  F.  Olfactory  bulbs.  G.  Optic  tract.  I.  Olfactory  root. 
J.  Corpus  callosum.  K.  Parietal  sulcus.  S.  Sylvian  depression.  T.  Limbic 
fissure.     The  types  of  cortex  are  indicated  by  the  subjacent  scheme. 

PLATE  II.  Page  70. 

Fig.  1.  Illustrative  of  the  "Motor  Type"  of  Cortex. 

Taken  from  the  left  hemisphere  of  the  brain  of  the  pig  to  exhibit  its  five- 
laminated  type  with  the  nests  or  clustered  ganglionic  cells,      x  76. 

Fig.  2.  "Motor  Cortex"  of  Pig. 
Nerve-elements  of  second,  third,  and  fourth  layers  respectively,      x  306. 

PLATE  III.  Page  88. 

Fig.  1.  Illustrative  of  the  "  Sensory  Type  "  of  Cortex. 
Taken  from  the  first  annectant  gyrus  of  human  brain,      x  65. 

Fig.  2.  "  Sensory  Type  "  of  Cortex. 

Nerve-elements  of  the  third,  fourth,  fifth,  and  sixth  layers  of  first  annectant 
gyrus  of  human  brain,      x  157. 

PLATE  IV.  Page  94. 

Fig.  1.  "Sensory  Cortex." 

Taken  from  the  "  modified  upper  limbic  "  type  in  the  brain  of  the  rabbit. 
This  area  is  represented  in  the  small  figures  of  the  rabbit's  brain  on  tliis  plate  by 
the  dotted  area  covering  the  inner  and  mesial  aspect  posteriorly,  internal  to  the 
parietal  sulcus,  K. 

b 


DESCRIPTION    OF    PLATES. 


Fig.  2.   "Modified  Olfactory  Type." 

Taken  from  the  posterior  extremity  of  the  lower  limbic  arc  of  the  rabbit's  bniin. 
The  area  is  represented  in  the  first  of  the  three  figures,  and  is  lettered  T.  The 
large  swollen  cells  of  the  second  layer  is  a  notable  feature  of  this  cortical  area. 
X  :210. 

PLATE  V.  Page  106. 

Section  through  "Motor  Cortex"  of  Brain  of  Cat. 

Specially  prepared  to  show  relationships  existing  between  the  nerve-cells  and 
the  lymphatic  channels  and  saccules  of  cortex.  The  connection  of  the  pericellular 
sacs  with  the  blood-vessels  is  clearly  indicated,  as  is  also  the  arching  of  the 
nutrient  vessel  aroimd  the  nerve-cell.  The  perivascular  nuclei  in  some  cases 
alone  indicate  the  position  of  the  lymphatic  sheath. 

PLATE  VI.  Page  458. 

Fig.  1.  Degeneration  of  Medullated  Fibres  in  Lateral  Columns  of  Spinal 
Cord  forming  so-called  "Miliary  Sclerosis,"  as  seen  under  a  Low- 
power  Objective. 

The  pale  nodular  structures  are  the  "miliary  "  patches  into  which  varicose  and 
moniliform  fibres  are  seen  to  pass  ;  most  of  such  patches  are  multilocular,  and  are 
surrounded  by  deep-stained  sclerosed  tissue. 

Fig.  2.  "Colloid"  Patches  resulting  from  Degeneration  of  Medullated 
Fibres  of  Spinal  Cord — more  Highly  Magnified. 
The  multilocular  constitution  of  the  patch  is  indicated  by  delicate  outlines ; 
axis-cylinders  devoid  of  medulla  are  seen  passing  into  the  degenerated  focus  ;  and 
a  scavenger-cell  is  seen  thrusting  its  ramifying  processes  into  the  substance  of  the 
colloid  patch. 

Fig.  3.  "  Colloid  "  Patch  still  more  Highly  Magnified  to  .show  the 
Outline  of  Multilocular  Material  with  a  Fine  Stroma  of  Elastic 
Fibres  Around,     x  350. 

PLATE  VII.  Page  462. 

Degeneration  of  Nerve-fibees  of  Lateral   Columns  of  Spinal  Cord  in 
so-called  "Colloid  Degeneration"  of  these  Tracts. 

The  axis-cylinders  are  seen  stripped  of  their  medullated  sheath,  or  surrounded 
by  moniliform  medulla  undergoing  granular  degeneration,  each  witli  a  super- 
imposed nucleus,  which  really  represents  a  young  scavenger-cell.  At  other  parts 
of  the  field  the  medulla  is  seen  in  process  of  segmentation,  and  attiicked  by 
scavenger-cells  crowded  with  granular  contents. 

PLATE  VIII.  Page  466. 

"Colloid  Degeneration." 

Portion  of  inferior  olivary  and  accessory  olivary  bodies  in  a  case  of  glosso-labio- 
laryngeal  paralysis  (T.  W.,  p.  466),  showing  spheroidal  products  of  degenerated 


DESCRIPTION    OF    PLATES.  xix 

ineduUated  fibre,  unci  the  complete  immunity  from  morbid  change  presented  by 
the  grey  matter.       x  22. 

PLATE   IX.  Page  472. 

Pig.  1. — "Colloid  Degenkration. " 

Showing  degeneration  of  the  medullated  arciform  fibres  of  the  first  layer  of  the 
cortex  in  a  case  of  chronic  alcoholic  insanity.  A  deep-stained  sclerous  belt  bounds 
the  outer  zone,  crowded  with  degenerated  products  of  medullated  fibre  forming 
"colloid"  bodies  arranged  in  linear  series.  Active  scavenger-cells  are  seen 
scattered  profusely  throughout  the  morbid  patch.      x  350. 

Fig.  2. — "Colloid"  Transformation  of  Medullated  Fibre  forming  the 
Arciform  Stripe  of  the  Peripheral  Zone  op  the  Cortex  in  a  Case  of 
Advanced  Senile  Atrophy  of  the  Brain. 

Numerous  scavenger-cells  are  scattered  amongst  the  degenerate  fibres,  and  oil- 
globules  crowd  upon  the  vessels  in  their  vicinity.      x  350. 

PLATE    X.  Page  480. 

To  Illustrate  Sclerosis  of  Cerebellar  Cortex  in  a  Case  of 
Epileptic  Imbecility. 

A.  Healthy  leaflet  closely  adjoining  diseased  tract,  showing  the  cells  of  Purkinje 
uninvolved. 

B.  The  sclerosed  leaflets  united  firmly  together,  the  cells  of  Purkinje  absent, 
and  the  normal  structure  completely  altered. 

PLATE    XL  Page  488. 

To  Illustrate  Sclerosis  of  Cornu  Ammonis  in  Epileptic  Insanity. 

A.  Peripheral  zone  in  gyrus  hippocampi. 

B.  Vacuolated  cells  beneath  the  above. 

PLATE    XII.  Page  496. 

Vacuolation  of  Nuclei  of  Nerve-Cells. 

To  illustrate  extreme  degrees  of  this  change  in  the  elements  of  the  second  and 
third  layers  of  the  cortex— human  brain.  The  nucleus,  which  in  the  normal  state 
should  stain  much  deeper  than  the  cell,  remains  colourless  or  is  swollen  into  one 
large  vacuole.  At  times  such  a  vacuole  appears  to  have  burst  through  tlie 
cell-protoplasm,  or  the  latter  contains  numerous  small  vacuoles,  the  unafl'ected 
protoplasm  still  staining  deeply. 

PLATE   XIII.  Page  502. 

Extreme  Degrees  op  Vacuolation  in  the  Multipolar  Ganglionic 
Cells  of  Spinal  Cord. 

The  coincidence  of  granular  degeneration,  and  vacuolation  is  here  seen.  The 
cells  are  swollen  with  bright  translucent  contents,  or  indurated  and  devoid  of 


XX  DESCRIPTION    OF    PLATES. 

branches.     The  retracted  protoplasm  and  displaced  nucleus  are  evident  features. 
X  3.J0. 

PLATE  XIV.  Page  508. 

Fuscous  Degeneration  of  Large  Ganglionic  Cells  from  the 
Motor  Cortex  of  Human  Brain. 

The  pale  patches  represent  the  areas  of  pigmentary  degeneration,  the  mass  being 
coarsely  granular  and  of  bright  yellow  tint.  The  unaffected  protoplasm  is  seen 
retracted  and  stained  by  the  aniline  dye,  and  the  apex  of  one  of  these  cells  is 
pigmented  and  stunted.       x  .350. 

PLATE  XV.  Page  518. 

Fig.  1. — Fatty  Degeneration  and  Atrophic  Shrinking  of  the  Peripheral 
Zone  (1st  Layer)  of  Cortex  in  a  Case  of  Advanced  Senile  Atrophy 
OF  the  Brain,  taken  from  a  Section  of  the  Ascending  Frontal  Con- 
volution. 

Scavenger-elements  are  seen  profusely  scattered  through  the  upper  layers, 
invading  the  vascular-tracts  and  surrounding  the  nerve-cells.  The  latter  are 
diminished  in  numbers,  and  a  notable  sclerous  shrinking  of  these  superficial  layers 
of  the  cortex  is  evident.      x  130. 

Fig.  2.  Fatty  Disintegration  of  Cortex  in  a  Case  of  Advanced  Senile 
Atrophy  of  the  Brain. 
The  peripheral  zone  (first  layer)  is  here  delineated,  the  vascular  walls  as  well  as 
the  scavenger-cells  are  surrounded  by  collections  of  oil-globules  and  fatty  debris. 
X  350. 

Fig.  3.  Nerve-cells  from  the  Deeper  Layers  of  the  Cortex  undergoing 
Disintegration  and  Removal  by  the  Agency  of  Scavenger-cells  which 

SURROUNT)   them. 

The  ner%*e-cells  are  seen  in  different  stages  of  degeneration — swollen,  irregular 
and  deformed,  devoid  of  branching  processes,  or  reduced  to  a  formless  heap  of 
granular  debris  still  enclosing  the  nucleus.  The  scavenger-cells  contain  numerous 
coarse  granules  in  their  interior,  deeply  stained  and  similar  to  the  products  of 
nerv'e-disintegration  aroimd  them,      x  350. 

PLATE  XV  I.  Page  528. 

Fig.  1.  Granular  Degeneration  of  Nerve-cells. 

Taken  from  the  fifth  layer  of  motor  cortex  in  a  case  of  chronic  alcoholic  insanity. 
Proliferation  of  the  perivascular  nuclei  as  well  as  the  pericellular  elements  is 
evident,  and  a  coarse  granular  degeneration  of  the  ])rotoplasm  of  the  ners-e-cell 
has  occurred,      x  210. 

Fig.  2.   Invasion  of  Deepest    or  Spisdle-cell  Layer  of   the  Cortex  by 
Scavengeb-cells  in  a  Case  of  Chronic  Alcoholic  Insanity. 

The  blood-vessels  which  are  undergoing  fatty  degeneration  are  crowded  by 
perivascular  nuclei  and  surrounded  by  numerous  scavenger-elements,      x  ISO. 


description  of  plates.  xxi 

Fig.  3.  Aneurysmal  Dilatation  of  Perivascular  Sac  in  a  Case  of 
General  Paralysis,     x  210. 

PLATE  XVII.  Page  534. 

Scavenger-elements  in  first  layer  of  Cortex  of  Human  Brain,  Illus- 
trating their  mode  of  proliferation  and  permeation  of  the  Cortical 
Structure  by  their  Fibrillation. 

The  coarse  vascular  processes  may  readily  be  distinguished  from  the  finer  fibrils 
given  off  by  these  organisms,      x  240. 

PLATE  XVIIL  Page  538. 

Degeneration  of  Nerve-cells  in  Human  Cortex. 

Taken  from  a  section  of  the  motor  region  to  illustrate  the  mode  of  connection 
and  relationships  existing  between  the  scavenger-elements  of  the  lymph-connective 
system  and  the  cortical  blood-vessels.  The  swollen  granular  degenerated  nerve- 
cells  are  seen  attacked  on  all  hands  by  the  scavenger-elements,      x  210. 


DESCRIPTION    OF    CHARTS. 

Chart  A.  Chart  of  recoveries  in  insanity  of  the  climacteric.  Page  220. 

,,  „  recurrent  insanity. 

Chart  B.  Chart  of  recoveries  in  insanity  of  puberty  and  adolescence  in  both  sexes. 

Page  364. 

Chart  C.  Chart  of  recoveries  in  insanity  of  the  puerperal  and  lactational  periods. 

Page  390. 


DESCRIPTION    OF  WOODCUTS. 

FIG.  PAOB 

1.  Section  across   transition  region  of  medulla,   showing  decussation  of 

pyramidal  tract  and  nuclei  of  posterior  columns,         .         (Schwalhe),  6 

2.  Cross-section  of  medulla  oblongata  at  the  upper  decussation   of  the 

pyramidal  tract,  .......         (Schvalbe),  9 

3.  Section  of  medulla  oblongata  through  the  inferior  olivary  bodies,     ,,  11 

4.  Medulla  oblongata  and  pons  with  neighbouring  structures  seen  from 

behind :    schematic  representation  of    the   nuclei   of  origin   of  the 
several  cranial  nerves,  ....  {Landois  &  Stirling),         18 

5.  Section  through  pons  on  a  level  with  the  origin  of  the  great  root  of 

the  trigeminus,   ........(  Wernicke),         22 

6.  Horizontal  section  throiigh  hemispheres,  the  right  at  a   deeper   level 

than  the  left,       ......  {Landois  et  Stirling),         29 


XXU  DESCRIHTIUN    OF    WOODCUTS. 

FIO.  PAOl 

7.  Section   through   hemispheres    (vertical    transverse),    passing  through 

plane  of  middle  commissure,        .....       (Oeyenbaur),         50 

8.  Left  ascending  frontal  aud  parietal  convolutions,  seen  from  the  side, 

with  tlie  attached  frontal  gyri  included  in  scheme  of  examination  of 
detached  cell-groups,  .         .         .         . 102 

9.  Left  ascending  frontal  and  parietal  gyri,  with  the  attached   frontal 

convolutions,  as  seen  at  the  vertex,  to  illustrate  site  of  detached  cell- 
groups,        10.? 

10.  Mesial  aspect  of  human  brain,  illustrative  of  the  more  frequent  site  of 

localised  softenings,  in  order  of  precedence,        .....       -452 

IL  Lateral  aspect  of  human  brain  (right  hemisphere),  illustrative  of  the 

more  frequent  site  of  localised  softenings,  ......       452 

12.  Section  across  hemispheres  and  basal  ganglia,  illustrative  of  the  site 

of  localised  softenings,  in  order  of  precedence, 45S 

13.  Lateral  aspect  of  left  hemisphere  of  human  brain,  illustrative  of  the 

sites  of  election  of  atrophy,  in  order  of  precedence,    ....       457 


A    TREATISE 


MENTAL    DISEASES. 


PART  I.— ANATOMICAL  AND  HISTOLOGICAL  SECTION. 


Contents.— The  Spiual  Cord— The  Medulla  Oblongata— The  Mesencephalon— The 
Thalameucephalon- The  Prosencephalon — The  Encephalon  as  a  whole — The 
Cerebral  Cortex — Cortical  Lami nation. 


THE    SPINAL    CORD. 

The  cerebro-spinal  axis  consists  of  a  series  of  longitudinally  disposed 
columns  of  white  meduUated  nerve  fibre,  arranged  around  a  central 
axis  of  grey  ganglionic  substance,  which  in  its  turn  surrounds  a  central 
cavity  or  cavities.  Both  white  and  grey  columns  constitute  symmetri- 
cal and  bilaterally  disposed  halves,  reminding  us  of  the  double  gangli- 
onic cord  in  the  invertebrata,  and  are  connected  across  the  middle  line 
by  a  system  of  commissural  fibres,  and  by  certain  tracts  of  the  white 
columns  which  decussate  from  the  one  half  into  the  other  at  difierent 
levels  of  the  system.  We  have  certain  points  to  allude  to,  both  as 
regards  the  idea  of  "medullated  columns"  and  the  central  "grey  axis," 
as  well  as  the  "bilateral  symmetry"  referred  to,  ere  we  desci'ibe  in 
detail  the  structures  themselves. 

In  the  first  place,  the  central  grey  axis  surrounding  the  central 
cavity  should  not  be  considered  altogether  in  the  light  of  a  uniform 
column  of  grey  matter,  but  rather  as  a  series  of  ganglionic  masses, 
which,  fused  together  along  the  whole  length  of  the  spinal  cord, 
become  dissevered  into  separate  masses  in  the  medulla  Olblong'ata, 
and  into  the  much  larger  and  more  important  ganglionic  masses  at  the 
base  of  the  Cerebrum.  Although  fused  in  the  spinal  cord,  an  indica- 
tion of  the  primitive  ganglionic  type  of  the  invertebrata  can  still  be 
traced  in  the  enlargement  of  the  grey  substance  at  the  level  of  each 
spinal  nerve,  mapping  ofi",  as  it  were,  each  spinal  segment  from  its 
neighbour  above  and  below  it. 

In  the  next  place,  the  columns  of  white  medullated  fibre  are  not 
contmiwus  tracts  throughout  the  whole  cerebro-spinal  axis;  they  consti- 


2  THE    SPINAL    CORD, 

tute  rather  a  multiplicity  of  smaller  columns,  each  of  which  varies  in 
its  destination,  and  consequently  in  its  longitudinal  extent.  We  may 
correctly  presume  that — taking  as  tlu;  lowjest  course  pursued  by  these 
medullated  tracts  that  of  fibres  arising  from  the  grey  cortex  of  the 
cerebrum,  and  passing  down  the  whole  length  of  the  cord  to  terminate 
in  the  motor  cells  for  the  lower  extremities  in  the  lumbar  region — we 
have  between  these  and  the  shortest  every  intermediate  length  of 
medullated  fibre,  interrupted  by  the  ganglionic  masses  to  which  it  is 
<lestined.  The  shortest  fibres  will  probably  be  a  series  of  fibres  running 
as  longitudinal  commissures  between  the  neighbouring  spinal  segments 
alluded  to :  these  occur  in  the  anterior  and  posterior  columns  of 
the  cord. 

We  have  spoken  of  the  fibres  as  being  "  interrupted  "  by  the  grey 
matter,  by  which  we  must  understand  the  important  fact,  that  at  such 
points  an  organic  connection  is  established  between  the  nerve  fibres 
and  the  nerve  cells  which  abound  in  the  grey  matter  at  these  points  of 
interruption,  and  from  which  cells  a  fresh  start  of  fibres  is  made  into 
other  realms. 

With  respect  to  the  bilateral  symmetry  of  these  two  halves  of  the 
cerebro-spinal  axis,  it  must  be  also  stated  that  although  at  a  first  glance 
the  various  parts  constituting  the  brain,  medulla,  and  spinal  cord, 
would  appear  to  exactly  reproduce  such  symmetry  of  arrangement, 
yet  in  the  former,  a  lateral  asymmetry  is  detected  by  a  more  careful 
consideration  of  its  cortical  envelope,  the  convolutionary  surface  of 
which  varies  very  considerably  in  either  hemisphere  as  regards 
arrangement  and  complexity  of  gyri,  and  superficial  area  of  grey 
matter.  This  bilateral  asymmetry  apparently  conforms  to  the  extreme 
differentiation  in  structure,  accompanying  the  more  independent  func- 
tional activity  of  the  cerebral  hemispheres,  and  histological  research 
teaches  us  still  more  foi'cibly  how  infinite  become  the  possibilities  for 
this  hemispheric  differentiation. 

We  must  likewise  attend  to  the  reversal  of  conditions  in  the  case  of 
the  white  and  grey  matter  constituting  the  large  cranial  ganglionic 
structures  and  the  spinal  cord  respectively.  In  the  latter — the  spinal 
cord — the  grey  matter  is  central,  and  is  invested  externally  by  the  white 
nerve  fibre ;  in  the  formei',  as  the  cerebral  hemispheres  and  CBPe- 
iDellum,  the  white  medulla  is  central,  and  invested  externally  by  an 
envelope  of  grey  cortex.  We  need  only  state  here  that  the  last  is 
the  type  assumed  by  those  ganglionic  levels  which  form  the  starting- 
point  of  fibres  for  centric  destinations  :  the  first  is  the  type  assumed 
for  the  reception  of  such  centric  diffusions.  Wherever  centric  fibres 
terminate  in  this  radiate  manner,  there  the  grey  cortex  assumes  a  sort 
of  outer  capsular  investment  and  the  medullated  fasciculi  its  centric 


SUBSTANTIA    GELATINOSA    AND    VESICULAR    COLUiMNS.  3 

core.     We  sliall  find  tliis  appertain  to  the  radiating  fibres  received  by 

the  cerebrum,  the  cerebellum,  the  thalamus,  quadrig-eminal 
bodies,  the  g-eniculate,  and  the  inferior  olivary,  in  particular; 

and,  in  ahnost  all  alike,  we  shall  find  even  to  the  cerebral  hemi- 
spheres, a  zonular  layer  of  medullated  fibres  bounding  the  gi'ey  capsular 
investment. 

To  revert  to  the  lower  or  subordinate  levels,  or  the  spinal  axis,  we 
learn  to  familiarise  ourselves  with  the  disposition  and  longitudinal 
direction  of  its  various  columns  and  ganglionic  centres,  by  studying  a 
series  of  sections  taken  in  different  planes  and  at  various  levels.  For 
our  present  purpose,  however,  it  is  but  necessary  to  acquaint  ourselves 
with  the  appearance  of  its  parts  as  seen  in  transverse  section.  In  such 
a  section  carried  through  the  lurabar  enlargement  of  the  cord,  we  see 
the  irregularly  crescentic  masses  of  grey  matter  disposed  on  either  side 
and  connected  across  the  median  line  by  the  anterior  and  posterior 
commissures,  between  which  lies  the  minute  orifice  of  the  central 
canal.  The  anterior  cornu  or  horn  is  at  this  site  thick,  broad,  and 
bulbeus;  the  posterior  horn,  as  in  other  regions,  is  longer  and  narrower, 
directed  towards  the  groove  on  the  outer  surface  of  the  cord,  which 
separates  the  lateral  from  the  posterior  columns,  and  where  it  receives 
the  lateral  section  of  the  fibres  of  the  posterior  roots.  Somewhat 
expanded  at  its  extremity,  the  posterior  cornu  is  obliquely  truncated 
from  within  outwards,  and  capped  at  this  site  by  a  translucent  sub- 
stance, the  substantia  g"elatinosa  of  Rolando ;    the  expanded 

part  so  capped,  and  forming  the  greater  part  of  the  posterior  horn, 
being  called  the  caput.  The  connection  between  it  and  the  anterior 
horn  and  median  grey  is  called  the  cervix  or  nCCk  of  the  horn. 
Whilst  the  lateral  segment  of  the  posterior  roots  passes  into  the  caput 
cornu,  the  median-lying  fasciculi  arch  inwards  around  the  gelatinous 
substance  and  ascend  in  the  outermost  zones  of  the  posterior  column 
to  enter  the  horn  at  a  higher  level,  whilst  others  bend  downwards  into 
the  grey  tract.  Just  anterior  to  these  arched  fibres,  where  they  enter 
the  cornu,  and  on  either  inner  side  of  the  neck  of  the  horn,  is  found  in 
the  upper  lumbar  region  an  insignificant  cluster  of  nerve  cells,  which 
at  higher  levels  become  an  important  feature,  the  vesicular  COlumn 
of  Lockhart  Clarke. 

In  transverse  sections  the  cells  of  this  column  look  inflated  and 
spherical ;  they  are  really  fusiform,  as  seen  in  longitudinal  sections.* 
Commencing  above  the  third  lumbar  nerve,  this  formation  extends  up 
to  the  ninth  dorsal,  and  in  still  higher  regions  are  found,  occasionally 

*  These  cells  have  been  spoken  of  as  "bipolar,"  but  this  is  an  error,  since  few  of 
the  elements  fail  to  show  several  processes. 


4  THE    SPINAL    CORD. 

distinctly  clustered,  similar  cells  wliicli  appear  as  the  representatives 
of  the  same  formation.  Dr.  Ross  traces  this  formation  as  reappearing 
in  the  lower  end  of  the  medulla  oblongata,  where  he  considers  it  to  be 
represented  by  the  nucleus  common  to  the  origin  of  the  spinal  acces- 
sory, A-agus,  and  glossopharyngeal  nerves. 

A  similar  formation  appears  in  the  sacral  region  (origin  of  the 
second  and  third  sacral  nerves)  as  the  sacral  nucleus  Of  Stilling*; 
so  that  we  have  throughout  the  length  of  the  spinal  cord  and  lower 
end  of  medulla  an  interrupted  column  appearing  at  the  two  extreme 
ends  and  in  the  thoracic  division,  of  which  the  latter  is  far  the  more 
conspicuous,  and  lies  exactly  along  the  plane  of  emergence  of  the 
visceral  nerves  {Gashell). 

In  the  posterior  horn,  we  find  sparsely  scattered  cells  of  fusiform 
contour  and  of  small  size  (15  ^:«),  which  are  regarded  as  sensory 
elements  probably  in  connection  with  the  posterior  roots. 

The  anterior  horn  presents  in  cervical  and  lumbar  regions  most 
conspicuous  groups  of  multipolar  cells,  which  vary  much  in  their  dis- 
tribution with  changes  in  the  form  of  the  grey  matter  ;  these  groupings 
are  fewer  and  far  less  conspicuous  in  the  narrow  anterior  cornu  of  the 
dorsal  region.  The  more  important  groups  to  be  distinguished  are 
five — viz.,  an  inner  or  median,  an  anterior,  an  antero-lateral,  a  postero- 
lateral, and  a  central. 

Of  these  clusters  the  first  and  last  (median  and  central)  are  the 
least  constant ;  and,  in  the  lumbar  region  in  particular,  do  we  note 
the  absence  of  the  inner  or  median  groups,  although  even  in  this 
region  minute  elements  tend  to  appear  occasionally  in  a  somewhat 
clustered  arrangement  along  the  mesial  border  of  the  grey  matter ;  at 
all  times  the  inner  is  one  of  the  least  prominent  clusters  in  the  horn. 

Of  the  antero-lateral  and  postero-lateral  groups,  the  latter  is  the 
more  conspicuous,  both  as  regards  size  of  cluster,  dimensions,  and 
number  of  cells. 

These  two  groups  occupy  the  outer  margin  of  the  grey  horn,  the 
one  lying  in  front  of  the  other,  and  usually  occasioning  a  well-defined 
anterior  and  posterior  angular  pi-ojection  of  the  horn. 

Internal  to  these,  between  them  and  the  inner,  and  behind  the 
anterior,  lies  in  certain  regions  a  central  cluster,  also  a  well-defined 
group. 

In  the  upper  dorsal  and  lower  cervical  region  a  prominent  lateral 
projection  from  the  outer  side  of  the  grey  matter  betwixt  anterior  and 
posterior  horn  has  long  been  known  as  the  intermedio-lateral 
tract  of  Clarke  :  it  contains  a  cluster  of  cells  Avhich  higher  up  fuse 
with  the  postero-lateral  group  already  alluded  to. 

The  outer  margin  of  grey  is  behind   this  site  blended  in  a  coarse 


CONDUCTING    AND    COMMISSURAL    TRACTS.  0 

mesliwork  with  the  neighbouring  wliite   medullated   strands,  consti- 
tuting the  so-called  fopmatio  reticularis. 

The  white  medullated  suT)stance  of  the  cord  investing  this  central 
grey  mass  is  roughly  distinguished  into  an  anterior,  lateral,  and 
posterior  column — the  former  extending  to  the  outermost  roots  of 
the  motor,  nerves  :  the  second  from  this  point  back  to  the  attachment 
of  the  sensory  roots :  and  the  last  to  the  posterior  median  fissure. 
These  columns  are  each  of  them  further  mapped  out  into  separate 
tracts,  indicated  anatomically  by  a  distinct  groove  on  the  surface  and 
by  a  difference  in  the  dimension  of  their  fibres ;  or  by  the  results  of 
enibryological  research  indicating  their  medullated  development  at 
distinct  periods  of  life ;  or  again,  by  the  facts  of  the  Wallerian 
degeneration  resulting  from  physiological  experimentation  or  the 
processes  of  disease. 

By  one  or  other  of  these  means  we  ascertain  that  at  least  eight 
physiological  tracts  may  be  distinguished  in  the  white  substance  of 
the  spinal  cord.     These  may  be  classed  as  follows  : — 

Anteriorly — 1.  Anterior  or  direct  pyramidal  tract  (also  termed  the 
column  of  Tiirck). 
2.  Anterior  radicular  (or  root)  zone  (also  termed  anterior 
ground  fibres  of  Flechsig). 

Laterally —    3.  Lateral  or  crossed  pyramidal  tract. 

4.  Direct  cerebellar  tract. 

5.  Antero-lateral    ascending   tract    of  Gowers    (also    ex- 

tending forwards). 

6.  Lateral  limiting  layer. 

Posteriorly — 7.  Postero-external  (or  postero-lateral)  column  {column  of 
Burdach  :  2'>osterior  radicular  zone  :  posterior  ground 
fibres  of  Flechsig). 
8.  Posterointernal   (or  postero-median)  column   {column 
ofGoll). 

Direct  Pyramidal  Tracts. — A  certain  proportion  of  the  fibres  of 
the  anterior  pyi'amids  which  escape  decussation  in  the  medulla,  descend 
direct  on  the  same  side  of  the  cord,  forming  the  tract  which  more  or 
less  completely  bounds  the  anterior  median  fissure.  This  anterior 
pyramidal  tract  progressively  diminishes  in  size  from  above  down- 
wards, as  it  becomes  distributed  to  the  anterior  cornu  of  the  opposite 
side  by  a  continuous  decussation  of  its  fibres  throughout  its  course 
along  the  anterior  commissure.  It  usually  extends  to  the  mid-dorsal 
region,  but  occasionally  passes  down  as  far  as  the  lumbar  cord,  and  is 
found   to  vary  very  considerably  in   size  for  the   same  levels   of  the 


b  THE    SPINAL    CORD. 

cord  in  different  individuals,  according  to  the  more  or  less  complete 
pyramidal  decussation  at  the  lower  end  of  the  medulla.  There  are 
strong  reasons  for  regarding  the  fibres  of  this  tract  as  chiefly  destined 

for  tlio  upper  extremities. 

Crossed  or  Lateral  Pyramidal  Tract.— Constituted  by  the  larger 

proportion  of  fibres  from  the  anterior  pyramids*  which  undergo  decus- 
sation at  this  high  level  (see  fig.  1 ,  j)>j),  the  lateral  tract  passes  down 
in  the  posterior  section  of  the  lateral  columns,  becoming,  like  the  anterior 


Fig.  1. — Section  across  transition  region  of  medulla,  showing  decussation  of 
])yraniidal  tract  and  nuclei  of  posterior  columns. 


X,  Cell  gronp  in  base  of  posteriorrcornu. 

cc.  Central  Canal. 

5,  Lateral  column. 

a  and  5,  Cell  clusters  in  anterior  cornu. 

Ca,  Anterior  coruu. 

py.  Pyramidal  tract  from  lateral  columns 

decussating  at  d  as  tliey  ascend. 
f.l.a,  Anterior  longitiulinal  fissure. 


s.l.p,  Posterior  longitudinal  sulcus. 
n.g,  Nucleus  funiculi  gracilis. 
n.c.  Nucleus  funiculi  cuneati. 
H^,  Funiculus  gracilis. 
H^,  Funiculus  cuneati. 
c.e,  Neck  of  posterior  horn. 
g.  Head  of  i>osterior  horn. 
r.p.C.L,  Posterior  roots  of  first  cervical 
nerve. 

direct  tract,  progressively  diminished  in  size  to  the  lowest  level  of  the 
cord.  The  fibres  of  this  tract  pass  into  the  grey  substance  of  the 
anterior  cornu  between  the  two  horns,  to  become  connected  with  its 
motor  nerve  cells — probably,  through  the  intervention  of  a  ramifying 

*  In  rare  exceptions  even  less  than  half  tlie  pyramidal  fibres  decussate  at  this 
level  (Flechsig). 


POSTERIOR    AND    LATERAL    COLUMNS.  7 

plexus  of  nerve  fibrils  derived  from  the  processes  of  these  ganglion  cells. 
The  direct  and  crossed  pyramidal  tracts  represent  a  continuous  con- 
nection with  the  cortex  of  the  motor  area  of  the  Itrain,  passing  uninter- 
ruptedly in  this  course  through  the  crusta  of  the  cerebral  peduncle 
and  the  internal  capsule. 

Posterior  Median  Column. — This  wedge-shaped  column  of  fine 
nerve  fibres  lying  on  each  side  of  the  posterior  median  fissure,  scarcely 
recognisable  below  the  dorsal  region,  extends  from  this  site  upwards  to 
its  termination  in  the  clavate  nucleus  in  the  medulla.  It  increases 
steadily  in  size  from  below  upwards,  and  undoubtedly  receives  fibres 
in  part  from  the  sensory  nerve-roots  which  pass  into  this  column  by 
way  of  the  postero-external  column,  as  well  as  the  posterior  commissure. 

Postero-Lateral  Columns  cannot,  like  the  postero-median,  be  re- 
garded as  largely  a  continuous  tract  throughout  the  spinal  cord.  A 
gi'eat  part  of  their  bulk  is  constituted  by  the  inner  division  of  the 
posterior  nerve-roots  which,  curving  round  the  caput  cornu,  run 
obliquely  upwards  or  downwards,  or  directly  outwards,  to  enter  the 
grey  matter  of  the  horn ;  and  also,  in  part,  by  a  system  of  short, 
vertical,  commissional  fibres  passing  betwixt  different  levels  of  the 
grey  matter  throughout  the  whole  extent  of  the  cord.  Higher  up  in 
the  medulla  we  shall  find  that  this  column  terminates  in  the  CUncate 

nucleus. 

Direct  Cerebellar  Tract. — A  somewhat  flattened  fasciculus  form- 
ing the  marginal  zone  of  the  lateral  columns,  from  the  end  of  the 
dorsal  region  upwards,  lies  upon   the   outer  side   of  the  lateral   or 

crossed  pyramidal  tract;    its  fibres  arise  from  the  posterior 

vesicular  column  of  Clarke,  which,  as  we  have  seen  above,  com- 
mences at  the  level  of  the  third  lumbar  nerve.  It  gradually  augments 
in  size,  and  eventually  terminates  in  the  cerebellum,  passing  up  to  it 
along  the  restiform  tract  of  the  inferior  peduncle.  At  its  origin, 
and  high  in  the  cervical  region  also,  the  lateral  pyramidal  tract 
becomes  superficial  behind,  so  as  to  separate  it  from  the  posterior  cornu. 

Antero-lateral  Ascending"  Tract  (Gowers).— A  column  of  fibres 

extending  up  through  the  whole  length  of  the  cord  (occasionally  the 
seat  of  ascending  degenerative  changes)  has  been  described  by  Dr.  Gowers 
as  situated  in  front  of  the  crossed  pyramidal  and  direct  cerebellar  tracts. 
Passing  across  the  lateral  columns  on  a  level  with  the  posterior  com- 
missure and  reaching  the  surface,  this  tract  skirts  the  margin  of  the 
cord  almost  as  far  as  the  anterior  median  fissure.  The  tract  is 
regarded  as  a  sensory  tract  originating  from  root  fibres  of  the 
sensory  nerves  decussating  across  the  posterior  commissure.* 

*  Diagnosis  of  Diseases  of  the  Spinal  Cord,  First  Ed.,  1879;  and  Diseases  of  the 
Nervous  System,  vol.  i.,  pcage  122  (Gowei-s). 


a  THE    MEDULLA    OBLOXOATA. 

Anterior  Radicular  Zone  and  Lateral  Limiting*  Layer.— 

Tluse  may  be  considered  togetlier  as  constituting,  like  many  of  the 
fil)res  of  the  posterior  radicular  zone,  a  series  of  short  commissural 
fibres  uniting  the  grey  matter  at  different  levels.  In  the  case  of  the 
anterior  root  zone  a  certain  portion  of  the  fibres  decussate  at  the 
anterior  commissure,  and  thus  "  a  connection  may  be  established 
between  the  two  anterior  cornua  at  different  levels  "  {Gowers  *). 

We  might  summarise  in  the  following  short  scheme  the  probable 
relationships  of  these  tracts,  as  taught  us  by  the  Wallerian  degenera- 
tions following  upon  disease  or  physiological  experiment : — 

Short  commissural  vertical  tracts — 

(1)  Anterior  root  zones. 

(2)  Lateral  limiting  layer. 

(3)  Burdach's  columns  (in  part). 
Descending  motor  from  cortex  cerebri — 

(4)  Tiirck's  columns. 

(5)  Crossed  pyramidal  tract. 
Ascending  sensory  tracts — 

(6)  Goll's  columns  fi-om  posterior  roots. 

(7)  Direct  cerebellar  from  visceral  tract. 

(8)  Antero-lateral  ascending  from  ci'ossed  sensory  roots. 


THE   MEDULLA  OBLONGATA. 

A  transverse  section  taken  just  below  the  calamus  SCrlptorius 
so  as  to  reveal  the  central  canal  intact,  ere  it  opens  out  on  tlie  free 
surface  of  the  fourth  ventricle,  shows  us  the  central  grey  matter 
thrust  back  to  the  posterior  margin  of  the  section — yet  encroached 
upon  laterally  by  the  mass  of  the  clavate  and  CUneate  nuclei  on 
either  side.  The  central  grey  substance  situated  in  the  middle  line  is 
symmetrically  disposed  around  the  central  canal,  which  here  forms  a 
mere  elongated  slit.  Most  prominent  in  front,  it  presents  an  eminence 
on  each  side  of  the  median  raphe,  with  a  rich  nucleus  of  large  nerve 
cells,  really  disposed  in  double  clusters — the  nuclei  of  origin  of  the 
hypoglossal  nerve,  the  fibres  of  which  conspicuously  run  forwards 
towards  the  ollvary  region.  On  each  side  of  these  median  pro- 
minences, a  lateral  projection  of  grey  matter  also  occurs  in  front  of 
and  partially  surrounding  a  conspicuous  column  of  meduUated  fibres 
seen  in  transverse  section  encircled  by  meduUated  loops — the  solitary 

fasciculus,  fasciculus  rotundus  or  respiratory  fascicle.    From 

*  Loc.  clt.,  p.  12.3. 


CLAVATE    AND    CUNEATE    NUCLEI.  9 

this  point  the  central  grey  matter  inclines  hackwarcls  to  the  miclrlle 
line,  behind  the  central  canal,  and  at  an  acute  angle  to  the  former.  This 
sudden  inclination  backwards  is  necessitated  by  the  prominence  of  the 
Clavate  nuclei,  which,  lying  behind  the  central  grey  substance  and 
to  its  outer  side,  approach  each  other  near  the  mesial  line;  along  the 
backward  inclination  of  this  and  the  lateral  prominence,  nuclei  for  the 
origin  of  the  accessory  nerve   and  vago-accessory  system  are  found. 


•  Ip      JT'     nj    n^~  ^ 


f.la.  A- 

Fis-  2. — Cross-section  of  medulla  oblongata  at  the  upper  decussation 
of  the  pyramidal  tract. 


s.l.p.  Posterior  longitudiual  sulcus. 
H'^^  Funiculus  gracilis. 
n.g.  Nucleus  of  funiculus  gracilis. 
H",  Funiculus  cuneatus. 
n.c.  Nucleus  of  funiculus  cuneatus. 
n.c}-,  External  nucleus  of  funiculus   cu- 
neatus. 
a.  Y,  Ascending  root  of  trigeminus. 
g.  Substantia  gelatinosa. 
f.a,  f.ci},  f.d-,  External  arciform  fibres. 
F.r,  Formatio  reticularis. 
ii.l,  Nucleus  of  lateral  column. 


o^,  Accessory  olive. 

0,  Inferior  olivary  body. 

n.ar.  Nucleus  arciformis. 

py.  Pyramid. 

f.l.a.  Anterior  longitudinal  fissure. 

d.a,  Anterior  or  upper  decussation  of 

pyramids. 
71.  XII,  Nucleus  and  root  fibres  of  bypo- 

glossal  nerve. 
c.r,  Central  canal. 
n.XI,  Nucleus  of  spinal  accessory. 


On  each  side  of  the  centi'al  canal  a  column  of  fibres  enclosing  an 
elongated  nucleus  of  nerve  coi'puscles,  measuring  23  /t  x  11  /i, 
extends  forwards  towards  the  middle  line ;  and  here,  still  enclosed 
in  the  central  grey  area,  is  a  mesial  compact  cluster  of  small  cells. 
The  former  represents  the  nucleus  of  the  eminentia  or  fasciculus 
teres,    which   at   higher  levels   becomes  a  prominent  feature  on  the 


10  THE    MEDULLA    OBLONOATA. 

floor  of  tho  ventricle.  Root  fn)ri'.s  of  tlio  accessory  nerve  will  at  this 
level  be  traced  from  the  lateral  angle  or  eminence  of  the  grey  substance 
to  their  site  of  emergence  behind  the  olivary  body. 

Above  the  calamiis  scriptorius,  the  opening  up  of  the  central  canal 
on  the  floor  of  the  fourth  ventricle,  is  necessarily  attended  by  a 
recession  of  the  clavate  nuclei;  and  the  eminentiae  teretes,  which, 
as  we  stated,  formed  the  antero-lateral  boundaries  of  the  central  canal, 
become  now  exposed  on  the  surface,  as  the  innermost  column  seen 
in  this  lower  half  of  the  venti'icle,  on  either  side  of  the  median 
raphe.  Formerly  covered  by  the  ala  Cinerea,  which  represents 
the  nucleus  of  the  vagus,  the  fasciculi  teretes  pass  upwards  as  wliite 
columns,  strongly  contrasting  with  the  grey  of  the  vagus  nucleus ; 
and,  as  they  take  this  course,  they  lie  superjacent  to  the  hypo- 
glossal nuclei.  These  eminences,  therefore,  map  out  the  course 
of  the  hypoglossal  nuclei,  but  must  not  be  identified  with  that 
nerve,  as  they  belong  to  a  wholly  distinct  system.  Whilst  the 
white  columns  of  the  eminentite  teretes  become  wider  and  more 
pronounced  upwards,  the  ala  cinerea  disappears  l)etween  them  and  a 
more  external  eminence — the  aCOUStic  tubePCle — so  that  transverse 
sections  exhibit  on  either  side  of  the  median  raphe  from  within  out- 
wards the  eminentiae  teretes,  the  tuberculum  acousticum,  and 
lastly  the  restiform  columns. 

At  this  plane  the  central  grey  matter  is  consequently  unfolded 
outwards — a  strongly  marked  concavity  directed  backwards,  still 
characterises  this  region  of  the  ventricle ;  but  this  process  of  unfold- 
ing proceeds  at  higher  levels,  until  on  a  plane  with  the  striae 
aCOUSticae,  the  floor  of  the  ventricle  is  almost  flattened  out,  pre- 
senting only  a  gentle  depression  at  the  middle  line.  As  this  process 
of  unfolding  of  the  central  grey  matter  proceeds,  the  restiform  tract 
diverges  more  and  more  from  the  mesial  line ;  whilst  simultaneously 
the  central  grey  substance,  notably  in  the  region  of  the  hypoglossal 
nucleus,  becomes  shallower,  and  the  nucleus  itself  nearer  the  surface. 

Superficially  viewed  in  the  fresh  medulla  one  readily  sees  between 
the  diverging  restiform  columns  a  large  central  V?  divided  midway 
by  the  vertical  raphe  and  separated  from  the  plump  acoustic  tubercles 
on  either  side  by  a  well-marked  depression,  into  which  the  upper 
wedge-shaped  apex  of  the  ala  cinerea  plunges  and  loses  itself.  The 
anterior  border  of  the  grey  substance  now  loses  its  abrupt  pro- 
minences, and  assumes  a  gentle  sinuous  course  across  the  medulla 
from  one  solitary  fasciculus  to  the  other — the  several  wave-like 
summits  representing  the  site   of  the  hypogflOSSal   and   the  vag'O- 

accessory  nuclei  (fig.  3). 

Having  so  far  followed  the  disposition  of  the  central  grey  matter. 


ASCENDINfJ    ROOT    OF    FIFTH    NRRVK. 


11 


from  just  l)elow  the  opening-up  of  the  central  canal  to  the  level  of  the 
stria;  medullares  of  the  acoustic  nerve,  the  student  should  now  direct 
his  attention  to  a  cross-section  of  medullated  fibres  of  a  notable 
crescentic  configuration,  and  encircling  on  its  outer  side  a  coarsely 
reticulated  region  largely  made  up  of  deep  stained  connective  tissue. 


nX    ,  nX' 


ii.ar 

Fig.  3.— Section  of  medulla  oblongata 

n.t.  Nucleus  of  fasciculus  teres. 

n.XII,  Nucleus  of  hypoglossal  nerve. 

n.X  and  n.X^,  Nuclei  of  vagus. 

/.s,  Fuuiciilus  solitarius. 

11. g,  Nucleus  of  funiculus  gracilis. 

n.c,  Nucleus  of  funiculus  cuneatus. 

n.am.  Nucleus  ambiguus. 

C.r,  Restiform  tract. 

g,  Substantia  gelatinosa. 

a.  V,  Ascending  root  of  trigeminus  (fifth 

nerve). 
F.r,  Reticular  formation  of  lateral  column. 
a.X,  Root  fibres  of  vagus. 


through  the  inferior  olivary  bodies. 


o.a.l,  Outer  accessory  olive. 

?;.?,  Nucleus  of  lateral  columns. 

f.a.e,  Exterual  arciform  fibres. 

o.  Inferior  olivary  body. 

XII,  Emergent  root  fibres  of  hypoglossal. 

p.  Anterior  pyramid. 

n.ar,  Nucleus  arciformis. 

f.l.a,  Anterior  longitudinal  fissure. 

p.oJ,  Olivary  x»eduncle 

o.a.m,  Inner  accessory  olive. 

V,  Anterior  column. 

r,  jVTediau  raphe. 


These  conspicuous  structures  lie  laterally  disposed  near  the  margin, 
on  either  side,  in  all  sections  of  the  medulla  up  to  the  emergence 
of  the  trifacial  nerve  :  the  dark-stained  reticulum  is  the  representative 
of  the  substantia  gelatinosa  of  the  posterior  cornu.  The  medul- 
lated crescent  is  the  ascending  root  of  the  fifth  nerve,  representing 
the  ascent  of  the  remaining  portion  of  the  posterior  root  zone  of  the 
spinal  cord.  Drawing  an  imaginary  line  from  the  solitary  fasciculus 
outwards  to  this  crescent — to  its  anterior  border  in  the  lower  levels, 


12  THE    MEDULLA    OHLOXGATA. 

and  to  its  posterior  Ijordcr  in  tlic  higher  levels  near  the  acoustic — wc 
map  otl"  a  region  which  corresponds  to  the  posterior  columns  of  the 
spinal  cord,  and  their  continuation  as  the  inferior  peduncles  of  the 
cerebellum  :  this  region  lies  behind  the  imaginary  line  so  drawn. 

In  like  manner,  a  line  drawn  from  the  mesial  eminence  of  the  central 
grey  matter  obliquely  outwards  to  the  root  of  the  infi-rior  olivary 
body,  maps  off  the  remaining  portion  of  medulla  into  two  divisions, 
an  inner,  between  it  and  the  median  raphe ;  and  an  outer,  between  it 
and  the  former  line  di-awn  to  the  crescentic  root  of  the  fifth  nerve. 
The  inner  of  the  two  divisions  corresponds  to  the  anteriOF  COlumn 
of  the  cord ;  the  outer  division,  to  the  lateral  COlumns.  The  two 
imaginary  lines,  so  drawn,  correspond  to  the  direction  taken  by  a 
motor  system  and  a  mixed  motor  and  sensory  system  of  cranial 
nerves — the  former  line  corresponding  to  the  spinal  accessory,  pneumo- 
gastric  and  glosso-pharyngeal  nerves,  the  latter  to  the  hypoglossal. 
On  the  other  hand,  the  purely  sensory  acoustic  nerve  arises  from 
a  position  further  back  than  the  mixed  lateral  system  ;  and  above  the 
plane  of  the  latter  nerve  we  find  the  origin  of  other  cranial  nerves 
disposed  in  like  manner — viz.,  an  anterior  or  motor,  a  lateral  or 

mixed  system,  and  a  posterior  or  sensory  system. 

Reverting  now  to  the  posterior  of  these  three  divisions  of  the 
medulla,  which,  as  we  have  stated,  is  bounded  in  front  by  the 
emergent  root  fibres  of  the  mixed  lateral  system  of  nerves — we  note, 
first,  that  in  the  lower  plane  (below  the  calamus)  the  greater  mass  of 
this  region  is  constituted  by  the  derivatives  of  the  posterior  columns 
of  the  cord  and  their  nuclei.  The  columns  of  Goll  with  their  clavate 
nuclei,  and  the  columns  of  Burdach  (or  posterior  root  zones)  with  their 
cuneate  nuclei,  encroach  by  their  mass  upon  the  posterior  aspect  of 
the  central  grey  matter,  nearly  meeting  at  the  middle  line ;  and 
concealing,  in  this  way,  the  deeper  seated  nuclei  of  origin  of  the 
vagus  and  hypoglossal.  In  front  of  the  clavate  and  cuneate  nuclei  in 
the  same  territory,  lies  the  solitary  fasciculus,  and  the  ascending 
root  fibres  of  the  fifth  nerve  around  the  gelatinous  substance  of 
Rolando.  The  crescentic  I'oot-area  of  the  fifth  nerve  is  covered 
externally  by  the  fibres  of  the  direct  cerebellar  tract  from  the  cord ; 
whilst  behind  this  tract,  but  still  forming  the  outer  margin  of  the 
medulla,  is  a  narrow  zonular  layer,  representing  the  commencing 
restiform  tract  of  the  cerebellum. 

At  this  level  it  will  be  apparent  that  large  numbers  of  delicate 
arched  fasciculi  are  thrown  oft'  from  both  clavate  and  cuneate  nuclei; 
and  these,  passing  forwards  through  the  lateral  columns  of  the 
medulla,  terminate  in  the  inferior  olivary  body  of  their  own  side 
partially,  from  whence  fresh  fasciculi  start  to  reach  the  opposite  resti- 


RESTIFORM    AND    INNER    DIVISION    OF    CEREBELLAR    PEDUNCLE.         13 

form  tract,  whilst  the  more  posterior  fasciculi  cross  the  raphe,  and 
traverse  the  opposite  olivary  body  on  their  way  to  join  the  restiform 
tract  on  this  side.  Hence  the  clavate  and  cuneate  nucleus  of  each 
side  discharges  itself  by  an  extensive  series  of  arcuate  fibres  into  the 
ojyposite  restiform  tract,  through  the  intermediation  of  the  olivary  body 
partially  of  its  own  side,  and  partially  through  that  of  the  other  side. 
As  a  direct  result  of  this  projection,  we  find  in  our  sections  above  the 
calamus,  the  rapid  attenuation  of  these  nuclei  of  the  posterior  columns, 
with  a  corresponding  enlargement  of  the  restiform  tract  for  the  cere- 
bellum. At  these  higher  levels  the  unfolding  of  the  central  grey 
matter  is  permitted  by  the  lateral  recession  of  these  structures,  partly 
induced  by  the  attenuation  and  disappearance  of  the  two  nucleated 
masses,  and  partly  by  tlie  divergent  course  assumed  by  the  resultant 
restiform  tract  to  reach  the  cortex  of  the  cerebellum  and  its  dentate 

nucleus. 

Near  the  lower  angle  of  the  fourth  ventricle,  our  transverse  sections 
show  us  the  restiform  tract  as  a  very  conspicuous,  somewhat  pyriform 
area,  and  pale-stained  in  contrast  to  the  parts  behind  it,  from  the  close 
approximation  of  the  medullated  fibres  seen  in  cross-section,  none 
being  arranged  in  fasciculi.  Immediately  behind  this  tract,  however, 
is  a  much  deeper-stained  area,  lying  between  it  and  the  central  grey 
matter  and  solitary  fasciculus ;  it  is  notable  for  the  great  number  of 
small  round  or  oval  bundles  by  which  it  is  constituted,  measuring 
usually  90  /x  x  22  /x,  pale-stained,  and  enclosed  in  grey  matter  with 
a  meshwork  of  deeply-stained  tissue.  In  this  area,  which  covers  an 
irregularly  quadrilateral  space,  appear  many  large  multipolar  nerve 
corpuscles  with  large  nuclei ;  these  corpuscles  attain  the  dimensions 
of  32  [J.  X   20  [jj. 

The  medullated  formation  so  constituted  is  an  important  division 
of    the    medulla    to    recognise.       It   has    been    long    known    as    the 

inner  division  of  the  inferior  cerebellar  peduncle— the  resti- 
form tract  forming  the  outer  division  of  the  same  structure. 
Its  connections  above  are  with  two  nuclei,  situated  one  on  either 
side  of  the  median  line,  beneath  the  superior  vermiform  process 
of  the  cerebellum,  and  are  called,  since  their  discovery  by  Stilling, 
the  roof  nuclei.  Its  connections  below  have  been  variously  given. 
Stilling  believed  them  to  be  the  origin  of  the  clavate  and  cuneate 
columns ;  Meynert  shows  that  this  view  is  incorrect,  and  we  have 
already  seen  that  the  latter  .columns  are  in  complete  connec- 
tion with  the  restiform  tract.  It  would  appear  to  us  that  these 
internal  divisions  of  the  cerebellar  peduncle  break  up  into  arcuate 
fibres,  which  partly  pass  behind,  but  partly  traverse  the  hilus  of  the 
olivary  body  of  the  same  side,  and  thence,  crossing  the  median  raphe, 


14  Tin:    MEDULLA    OBLONGATA. 

terminate  in  tlic  groy  matter  of  the  opposite  olive.  Nearer  the 
calamus  Ave  find  that  the  clavatc;  and  cunoate  nuclei,  not  as  yet 
completely  resolved  into  arcuate  fasciCUli,  insinuate  themselves 
between  these  two  divisions  of  the  inferior  peduncle — a  little  higher, 
where  the  nuclei  have  disappeared,  these  cerebellar  columns  are,  as 
we  have  intimated,  in  juxtaposition. 

Passing  now  to  the  region  lying  in  front  of  the  emergent  root  fibres 
of  the  lateral  system  of  nerves,  between  them  and  the  motor  system 
(hypoglossal),  we  find  the  greater  part  of  this  area  occupied  by  the 
cross-section  of  ascending  fibres,  broken  up  into  numerous  minute 
groups  by  the  intertwining  of  complex  arcuate  fibres,  as  they  curve 
forwards  and  inwards  to  the  raphe  and  the  olivary  district.  To 
this  fasciculated  meshwork  the  term  reticular  formation  has  })een 
applied,  the  ascending  fibres  being  the  continuation  of  the  outermost 
part  of  the  anterior  root  zone.  Two  well-defined  nuclei  characterise 
this  lateral  column  of  the  medulla :  one,  which  is  the  richer  in  cells, 
is  elongated  and  directed  from  without  inwards,  approaching  the 
margin  of  the  lateral  column,  lying  parallel  with  the  roots  of  the 
lateral  mixed  nerves,  between  the  substantia  gelatinosa  behind,  and 
the  olivary  and  its  fillet  in  front. 

Further  inwards  in  this  lateral  column,  and  carried  backwards 
parallel  with  the  lateral  mixed  roots,  is  a  second  smaller  group  of  cells 
more  closely  clustered  than  the  former ;  nor  traversed  as  these  are  by 
dense  fasciculi  of  arcuate  fibres  passing  to  the  olivary  body.  The 
former,  called  the  nueleus  of  the  lateral  COlumn  by  Stilling  and 
Clarke,  might  be  more  conveniently  termed  the  external,  and  the 
second  cluster  the  internal,  nucleus  of  the  lateral  column  ;  or  following 
Dr.  Ross,  the  anterior  and  posterior  omcleus. 

They  almost  certainly  represent  motor  cell-groups  of  the  anterior 
cornua  of  the  spinal  cord,  severed  from  the  rest  of  the  central  grey 
matter  by  the  decussation  of  the  pyramids  across  to  the  lateral 
columns,  and  the  interposition  of  the  mass  of  the  inferior  olivary 
body.  By  Dr.  Ross  they  are  regarded  as  detached  from  the  antero- 
lateral and  postero-lateral  group  of  cells  in  the  anterior  cornu  by  the 
cleavage  effected  by  the  arcuate  fasciculi  of  the  medulla,  whilst  those 
main  groups  are  still  found  as  the  motor  nuclei  in  the  central  grey 
matter  of  the  medulla. 

Intei'calated  l)etwecn  the  lateral  columns  of  the  medulla  and  the 
anterior  or  median,  is  the  inferior  olivary  body,  extending  throughout 
the  region  we  have  been  studying,  but  terminating  at  the  level  of  the 
lowermost  fibres  of  the  ;;o??s.  Prominent  on  the  superficial  aspect  of 
the  medulla,  between  the  pyramids  and  the  lateral  and  restiform 
tracts,  it  looks  like  a  small  almond-shaped  body,  which  upon  trans- 


INFERIOR    AND    ACCESSORY    OLIVARY    BODIES.  15 

verse  section  reveals  a  grey  nucleus,  imhedchd  in  a  mcdullatcd  invest- 
ment oilo7igitudinal  Ghres — the  so-called  fillet  or  olivary  fasciculus. 
The  grey  nucleus  is  in  the  form  of  a  plicated  capsule  of  many  folds, 
constituted  of  numerous  cells  imbedded  in  grey  matter,  and  open 
towards  its  inner  side.  The  investing  medulla  of  longitudinal  fibres 
passes  inwards  and  forms  a  central  core  for  this  grey  capsule,  the 
fibres  of  which  then  spread  out  into  its  various  convolutionary  plica- 
tions to  terminate  in  the  cells  here  distributed  :  the  remaining  fibres, 
which  do  not  so  turn  inwards  to  the  grey  capsule,  pass  downwards 
into  the  lower  regions  of  the  medulla  and  cord.  We  have  already 
alluded  to  the  dense  intertwining  and  connections  of  the  cerebellar 
arcuate  fasciculi  within  these  olivary  bodies. 

In  the  lower  planes  below  the  calamus,  our  sections  exhibit  the 
olivary  capsule  open  in  front  at  its  hilus,  the  anterior  line  of  plica- 
tions being  shorter  than  the  posterior  :  and  here,  bordering  upon  this 
opening  in  the  capsule,  is  an  elongated  belt  of  grey  matter,  containing 
cells  similar  to  those  in  the  olivary  body — this  is  the  internal 
accessory  olive.  Sections  taken  midway  through  the  inferior  olive 
show  us  two  such  bodies ;  the  one,  as  before,  situated  in  the  anterior 
column,  separated  from  the  olivary  body  by  the  root  fibres  of  the 
hypoglossal,  and  greatly  segmented  by  the  passage  of  a  rich  system  of 
arcuate  fibres  to  the  raphe  :  the  other,  in  the  lateral  column  just 
behind  the  hilus,  like  a  concave  lens  with  its  concavity  towards  the 
olivary  capsule — this  latter  is  the  external  aCCCSSOry  olive.*  In 
histological  structure  both  resemble  the  larger  olivary  body,  and  by 
Meynert  they  are  regarded  as  continuous  with  its  capsule. 

The  most  external  arcuate  fasciculi  entering  the  restiform  tract  come 
to  it  by  way  of  the  anterior  pyramid  and  olivary  body,  partly  in  front 
of  and  partly  behind  (and  so  encircling)  the  former,  and  forming  a 
thick  stratum  of  fibres  over  the  external  aspect  of  the  olivary  body — 
its  stratum  ZOnale  :  and  lastly,  covering  in  like  manner,  the  ascend- 
ing root  of  the  fifth  nerve  to  end  in  the  restiform  tract.  A  similar 
investment  of  the  upper  olivary  body  exists,  as  we  shall  see  later  on  ; 
this  in  the  lower  mammals  is  uncovered  by  the  fibres  of  the  pons, 
which  do  not  conceal  them,  as  in  man,  and  constitute  the  so-called 
corpus  trapezoides.  The  zonular  layer  passing  over  the  anterior 
aspect  of  the  anterior  pyramids  is  aptly  referred  to  by  Meynert  as 
a  small  anterior  po7is. 

This  inferior  half  of  the  medulla,  with  which  we  have  for  the  present 
concerned  ourselves,  contains  the  nucleus  of  origin  and  emergent  root 
fibres  of  but  one  purely  motor  nerve — the  h7/poglossal — but  of  four  of 

*  These  bodies  are  also  known  as  the  "external  and  internal  parolivary 
bodies." 


16  THE    MEDULLA    OBLONGATA. 

tho  mixed  lateral  system,  viz.,  the  spinal-accessor)/,  vagus,  glo88o- 
pharijHijeal,  and  (the  ascending  root  of)  the  trifacial  or  fifth.  At  the 
anterior  mesial  prominence  of  grey  matter  in  these  planes,  we  find  the 
nuclei  of  the  hypo(jlot<><((l,  which,  prior  to  the  opening  up  of  the  central 
canal,  are  arranged  in  a  double  cluster  usually  termed  the  internal 
and  external  convolute  of  the  hypoglossal,  owing  to  the  loop-like 
arrangement  of  the  centric  and  peripheric  fibres  connected  with 
them.  The  external  also  lies  at  a  posterior  plane  to  the  internal. 
The  cells  are  large  and  uiulticaudate,  forming  the  most  conspicuous 
cell-groupings  in  the  whole  sectional  area  of  the  medulla :  they 
measure  60  il  x  20  //-.  The  centric  connections  of  these  nuclei 
consist  of  certain  straight  fibres  of  the  median  raphe,  which  run  back- 
wards as  far  as  the  central  grey  matter,  and  then  arching  outwards, 
form  spirals  around  the  front  and  outer  border  of  each  nucleus,  and 
are  connected  with  its  large  cells  :  thence,  similarly  curving  around 
the  inner  border  to  pass  obliquely  outwards,  are  the  peripheric  fasciculi 
— the  rootfihres  of  the  hyporjlossal.  These  emerge  from  between  the 
pyramid  and  the  olivary  body,  some  fasciculi  traversing  the  latter  in 
their  course.  In  vertical  extent  this  centre  of  origin  stretches  from 
just  above  the  level  of  the  decussation  of  the  pyramids  to  the  strioz 
viedullares  of  the  acoustic  nerve ;  but,  as  we  distance  the  calamus, 
the  groups  become  less  definite  and  merged  into  a  less  characteristic 
form,  far  less  rich  in  cells.  Thi-oughout  the  wliole  of  this  extent,  the 
vertical  column  of  cells  gives  origin  to  emergent  radicles,  which  issue 
anteriorly. 

External  to  the  hypoglossal  nuclei  lie  the  lateral  projections  of 
the  central  grey  matter,  in  the  angle  of  which  we  find  the  sensory 
nuclei  of  origin  of  the  mixed  lateral  system  of  nerves,  so  named  from 
their  possessing  both  motor  and  sensory  filaments.  Some  seven  roots 
of  origin  are  enumerated  by  Meynert  for  this  system  of  nerves  ;  and  it 
is  probable  that  the  three  nerves  of  this  system  in  the  lower  half  of 
the  medulla  ai'ise  in  a  very  similar,  if  not  identical,  manner  from 
closely  associated  nuclei,  some  of  which  are  common  to  two  nerves. 
The  two  more  important  nuclei  of  origin  for  this  system  are — the 
motor  nucleus  of  the  mixed  nerves,  and  the  sensory  already  alluded  to. 

The  motor  nuclei  are  found  in  advance  of  the  central  grey  substance, 
disposed  in  the  lateral  columns  of  the  medulla.  A  somewhat 
elongated  cluster  of  large  nerve  cells,  from  which  motor  fiisciculi 
emerge  and  run  backwards  pai-allel  to  the  emergent  root  fibres  of 
this  system  of  ner^•es,  is  the  more  important  of  this  mode  of  origin ; 
but,  fibres  running  in  the  same  direction  can  also  be  traced  further 
outwards,  to  the  nucleus  of  the  lateral  column,  between  the  ascending 
root   of  the  .fifth   and   the  inferior  oli\ary  body.     Much  discrepancy 


SPINAL    ACCESSORY,    VAGUS,    GLOSSO-PIIAUYXGEAL.  17 

appears  with  respect  to  the  descriptions  given  to  these  anterior  roots 
of  origin  of  the  mixed  lateral  system ;  some  autliorities  .speak  of  an 
anterior  and  posterior  nucleus  of  the  lateral  column ;  others  describe 
these  fibres  as  being  doubtfully  roots  of  the  system  ;  whilst  others 
with  Meynert  refer  to  one  nuclear  column  of  origin  distinct  from  the 
nuclei  of  the  lateral  column.  In  fact,  Meynert  traces  this  motor 
nucleus  as  a  nucleus  of  the  spinal  accessory  downwards  to  the  lateral 
process  of  the  anterior  horn,  and  finds   its  analogue  on  higher  levels 

in  the  inferioF  facial  and  motor  nucleus  of  the  trigeminal.* 

Our  own  view  of  the  case  would  be  in  accordance  with  that  of 
Meynert ;  in  addition  to  which,  however,  we  would  assign  to  the 
external  nucleus  of  the  lateral  colitmn  a  partial  site  of  origin  for  these 
motor  rootlets.  The  important  fact  for  the  student  to  bear  in  mind 
is  that  these  motor  nuclei  are,  in  accordance  with  the  spinal  cornual 
scheme,  in  advance  of  the  sensory  division,  and  reach  the  main  roots 
by  I'ecurrent  fascicvili  curving  round  the  vagus  nucleus  from  the 
inner  to  the  outer  side ;  and  this  type  is  repeated  for  the  motor  roots 
of  the  facial  and  trigeminal  nerves. 

The  sensory  nucleus  or  posterior  nucleus  for  these  three  mixed 
nerves  is  a  somewhat  compact  formation  of  nerve  cells,  clustered 
within  the  lateral  angle  of  the  central  grey  substance  at  the  lower 
planes  of  this  region,  where  it  forms  the  vago-accessory  nucleus. 
A  little  difficulty  may  be  experienced  in  distinguishing  between  the 
nucleus  of  origin  for  the  three  nerves,  if  we  do  not  attend  to  the  fact 
that  so  long  as  arcuate  fibres  are  seen  distributed  to  the  solitary 
funiculus  from  the  raphe,  we  are  in  the  region  of  origin  of  the  spinal 
accessory  and  beloio  the  vagal  nucleus ;  the  latter  centre  can  also  be 
difierentiated  into  two  groups,  an  external  and  internal  nucleus, 
described  by  Lockhart  Clarke,  a  similar  arrangement  prevailing  for 
the  glosso-pharyngeal  centres.  From  the  apex  of  this  grey  prominence, 
which  represents  a  sensory  column  of  origin  for  these  nerves,  pass 
outwards  tlie  main  root  fibres — the  spinal  accessory  between  tlie 
olivary  bodies  and  gelatinous  substance ;  the  vagus  and  glosso-pharyn- 
geal through  the  latter,  and  traversing  in  their  course  the  ascending 
roots  of  the  fifth  nerve  ere  they  emerge  at  the  surface.  Immediately 
outside  the  origin  of  this  root,  at  the  posterior  or  sensory  nuclei,  is 
the  conspicuous  cross-section  of  the  solitary  fasciculus,  which 
really  represents  an  ascending"  rOOt  for  the  same  mixed  lateral 
system.  We  have  seen  that  a  dense  arcuate  system  passes  into  it  from 
the  median  raphe  (centric  fibres)  below  the  origin  of  the  vagus ;  we 
may  also  just  as  readily  trace  fibres  issuing  from  this  ascending  root  to 
join  the  emergent  roots  of  the  accessory,  vagus,  and  glosso-pharyngeal 

*  PsycMalry,  translated  by  Sachs,  part  i.,  p.  124. 


18 


THE    PON'S    VAKOLII. 


nerves.  The  posterior  sensory  nucleus  is  regarded  by  Dr.  Ross  as 
the  representative  of  the  vesicular  COlumns  Of  Clarke  in  the 
spinal  cord  from  their  relative  position,  connections,  character  of 
the*cells,  and  their  distribution. 

A  fourth    root  easily   traced  in  the   region   of  the   vagus,   is    one 


/'anlicuiu 
Corinis    j 
quiulri-  -. 
geiniuuin  (^posticum 


Locus  coerule«3   - 


Eiuinentia  tere: 


CruK  cerebelli 

ad  pontem 

or 

MLMle  cerebellar 

peduncle. 


Con&rium  or  pineal  gland. 


Urachlum  coDJunctivum  auacuin. 


Bracliium  coEjunctlv 
posticum. 


Corpus  geiiiculatum 
uedialt^ 


Pedunculus  cerebri. 


ad  corpora  quadri-^ 
pctnina.  or  1 

\ superior  ciTCbellar  1 

il  pedunclt.  \ 


ad  mcduUam  oblon 

fatam,  or  interior 

cerebellar 

peduacle. 


J' 


Ala  cinerca 
Acc^ssorius  nucleus 


Funiculus  cuneatus 
(Part  of  rcsliform  body). 


Funiculus  cracUis 
(I'ORtorior  iivr.imid). 


Fig.  4. — Medulla  oblongata  and  pons  with  neighbouring  structures  seen  from  behind  : 
schematic  reiireseutation  of  the  nuclei  of  origin  of  the  several  cranial  nerves. 


which,  emerging  from  the  raphe,  traverses  the  front  of  the  hypoglossal 
nucleus,  and,  following  the  curve  of  the  grey  substance  anteriorly, 
enters  the  vagus  nerve.  In  traversing  the  gelatinous  substance  also, 
the  vagus  and  glosso-pharyngeus  both  derive  fibres  from  the  former 
ere  they  issue  from  the  medulla ;  this  is  the  fifth  root  of  origin  for 


ABDUCENS,    FACIAL,    AND    ACOUSTIC    NUCLEI.  19 

tlies(^  nerves.     Another  small  fasciculus  has  been  described  by  Clarke 
as  passing  from  thc^  fasciculus  tePGS  into  the  vagUS. 

The  Upper  Half. — Passing  now  to  the  upper  Jialf  of  the  medulla, 
which  upon  its  ventricular  aspect  is  like  the  lower  half  triangular 
in  outline,  its  base  being  mapped  out  by  the  acoustic  stride  and  its 
lateral  boundaries  formed  l)y  the  superior  cerebellar  peduncles,  con- 
verging to  the  quadrigeminal  bodies,  we  meet  first  with  tioo  motor 
nerves  closely  associated  in  their  origin,  and  arising  as  do  the  motor 
cranial  nerves  generally,  from  an  anterior  or  median  position  on 
either  side  of  the  raphe ;  and  one  purely  sensory  nerve,  which  takes 
its  origin  in  accordance  with  the  same  morphological  principle  alluded 
to,  from  a  lateral  and  posterior  plane.  The  two  motor  nerves  are 
the  sixth  and  seventh  pair,  or  the  abducens  and  facial ;  the  sensory 
nerve  is  the  eighth,  the  aCOUStlC  or  audltory.  The  nuclei  of  origin 
for  these  three  nerves  do  not  occupy  the  same  vertical  plane ;  that 
for  the  sixth  is  the  highest,  next  below  it  comes  the  facial  nucleus, 
and  lowest  of  all  the  acoustic  nuclei — yet  they  each  successively 
overlap  the  other,  the  internal  acoustic  nucleus,  as  we  have  already 
seen,  descending  also  below  the  base  of  the  arbitrary  triangular  space 
drawn  by  the  strise  medullares.  As  in  the  lotmr  triangular  area  of 
the  grey  floor  below  the  striae,  we  found  the  nuclei  of  a  motor 
(XII)  and  three  mixed  nerves  (IX,  X,  XI)  associated  through  a 
great  part  of  their  extent  with  the  accessory  body — the  inferior 
olivary  ;  so  in  this  upper  triangular  division  we  find  a  very  similarly 
constituted  structure — the  superior  olivary  body — occupying  a 
vertical  plane  corresponding  very  nearly  to  that  of  the  two  motor 
nerves — the  sixth  and  seventh. 

Transverse  sections  across  the  levels  of  emergence  of  these  latter 
nerves  exhibit  a  notable  change  in  the  distribution  of  the  various 
structures  in  front ;  the  inferior  olivary  bodies  have  disappeared ;  the 
pyramids  still  maintaining  their  integrity  as  independent,  compact 
columns,  are  now  concealed  beneath  the  most  anterior  fibres  of  the 
middle  cerebellar  peduncle  {^wns),  which  enclose  them  between  their 
transversely  disposed  fasciculi,  as  a  more  superficial  and  a  deep 
series  of  fibres ;  whilst  laterally  the  brachia  of  the  pons  diverge 
to  the  cerebellum,  and  further  back  the  restiform  and  internal 
divisions  of  the  inferior  cerebellar  peduncles  in  like  manner  pass 
to  their  distribution.  On  a  level  with  the  stride  medullares  an  in- 
termediate transitional  stage  is  apparent ;  and,  as  we  pass  to  higher 
planes,  the  inferior  olivary  body  loses  its  outward  inclination,  its 
long  axis  becoming  disposed  antero-posteriorly  and  immediately  be- 
hind the  two  pyramids.  Thus  a  lateral  constriction  occurs  which 
gives  the  medulla  here  from   before  backwards  an  apparent  but  not 


20  THIC    PONS    VAROLII. 

absolute  incrcasrcl  dcptli.  This  antero-postorior  dopth  appears  still 
more  exaggerated  by  the  lower  loops  of  the  pons  capping  the  pyramids 
in  front,  mIucIi  have  just  been  caught  at  this  plane  and  divided. 
In  such  sections  the  nucleus  of  the  lateral  column  is  still  well  seen 
between  the  diminished  olivary  body  and  the  ascending  root  of  the 
jxj'th  nerve,  whilst  immediately  jDosterior  to  the  inferior  olives  is  a 
group  of  large  fusiform  and  multicaudate  cells,  the  former  in  connec- 
tion with  the  arcuate  system  here,  the  latter  in  apparent  connection 
with    fasciculi    which    pass   backwards    to    the    median   or  motOP 

column  of  grey  matter. 

Still  somewhat  higher,  the  inferior  olive  ceases,  or  may  present 
its  upper  extremity  as  a  single  minute  plication ;  and,  in  this  region, 
we  find  the  nucleus  of  the  lateral  column  compressed  into  a  long 
narrow  tract  by  the  interposition  between  it  and  the  ascending  root 
of  thefiftlt,  nerve  of  a  very  notable  large  nucleus  of  almost  spherical 
outline,  and  by  the  disposition  of  its  enclosing  fibres,  severed  appar- 
ently into  a  series  of  convolutes  of  large  multicaudate  cells.     This  is 

the  anterior  or  inferior  nucleus  of  the  facial  nerve,  and  from 

it  a  somewhat  wide  belt  of  sparsely  scattered  fasciculi  pass  back  to 
ascend,  as  Ave  shall  see  later  on,  as  the  genu  of  the  facial  nerve, 
whilst  the  compressed  nucleus  of  the  lateral  columns  sends  in- 
distinctly marked  fibres  towards  the  median  grey.  The  superior 
olivaiy  does  not  as  yet  present  itself;  in  this  plane  we  may  study 
the  various  nuclei  of  origin  of  the  auditory  nerve.  Following  the  grey 
matter  of  the  floor  of  the  ventricle  outwards  from  the  median  pi-omi- 
nence  (which  here  is  remarkably  shallow),  we  find  it  progressively 
increases  in  depth  to  its  extreme  lateral  limits,  where  the  lateral  or 
sensory  projection  is  a  notable  feature,  and  the  large  internal 
auditory  nucleus  is  seen.  Immediately  outside  this  sensory  nucleus  is 
the  tesselated  area  characterising  the  inner  division  of  the  inferior  cere- 
bellar peduncle ;  followed  still  further  outwards  by  the  transverse  section 
of,  the  crescent-like  resfi/urm  tract.  To  the  inner  side  of  the  restiform 
tract  the  conspicuous  ascending  root  of  the  fifth  nerve  is  applied. 

The  whole  of  the  structures  above  noted — the  grey  floor  Avith  its 
lateral  prominence,  the  inner  peduncular  tract,  and  the  restiform 
column — are  embraced  superficially  by  a  zonular  investment  of  fibres 
issuing  from  the  region  of  the  raphe ;  in  fact,  the  striiv  medxUarcs, 
which,  reinforced  further  on  by  others  emerging  from  the  restiform 
tract,  constitute  the  posterior  root  of  the  auditory  nerve. 

On  the  other  hand,  these  same  structures  aboA^e  enumerated,  are 
embraced  from  loithin  by  the  anterior  auditory  root,  Avhich  runs 
chiefly  betAveen  the  restiform  tract  and  the  ascending  root  of  the 
fifth,  although   many  of  its   fasciculi   traverse   the   structure  of  the. 


NUCLEI    OF    ACOUSTIC    NERVE.  21 

latter.  The  student  sliould  remark  lioro  tliat  tlio  fifth  ascondiii'r 
root  serves  always  to  distinguish  to  him  the  emergent  roots  of  the 
facial  from  those  of  the  auditory ;  the  facial  lying  to  the  inner,  and 
the  auditory  to  the  outer  side  of  this  root. 

The  anterior  root  of  the  acoustic  passing  inwards  in  front  of  the 
restiform  column  divides  into  the  following  root  fasciculi : — 

(a.)  An  inner  series  passing  into  the  internal  aCOUStic  nucleus, 
with  the  cells  of  which  it  is  connected. 

(5.)  A  median  series  passing  in  part  to  the  cells  of  the  external 
acoustic  nucleus  (connected  with  the  inner  peduncular  division) ; 
and  in  part  to  the  restiform  tract. 

(c.)  An  outer  series  passing  into  the  anterior  aCOUStic  nucleus, 
which   is   situated    between    the   restiform    tract,   auditory    root,   and 

flocculus. 

The  connections  of  the  auditory  nerve  roots  with  the  cerebellum 
are  to  a  great  extent  unknown.  According  to  the  belief  of  Meynert, 
the  divisions  of  the  anterior  root  take  a  decussating  and  non-decus- 
sating course  \  the  two  median  and  the  outer  pass  direct  into  the 
cerebellum  through  the  inferior  peduncles  of  the  same  side ;  whilst 
the  inner  pass  from  the  internal  acoustic  nucleus  across  the  raphe 
partly  through  the  internal,  partly  through  the  external  acoustic 
nuclei  of  the  opposite  side,  and  thence  up  the  internal  division  of  the 
peduncle  to  the  cerebellum.  These  obliquely  ascending  fasciculi  give 
rise  to  the  superficial  striae  on  the  floor  of  the  ventricle,  the  so-called 
sound-rod  of  Bergmann.  The  posterior  roots  empty  themselves 
partly  into  the  restiform  columns  of  their  own  side,  and  partly  as 
superficial  and  deep  arcuate  fibres  across  the  raphe  into  the  inner 
peduncular  division  of  the  opposite  side,  and  thence  ascend  to  the 
cerebellum.  In  this  course  the  superficial  series  form  the  well-known 
acoustic  striae  or  striae  meduUareS,  and  do  not  come  in  contact 
with  the  internal  acoustic  nucleus ;  the  deep  arcuate  series,  however, 
traverses  the  nucleus  of  its  own  side,  and  crossing  the  raphe  joins 
the  cells  of  the  opposite  internal  acoustic  nucleus  ere  it  enters  into 
its  centric  expansions  by  the  peduncular  route. 

At  higher  planes  of  the  medulla  wherein  the  superior  olivary  body 
appears,  we  reach  the  radicular  zones  of  the  facial  and  the  abducens. 
The  motor  area  of  the  grey  floor  of  the  ventricle  at  these  levels  presents 
in  transverse  sections,  two  strongly  defined  eminences  separated  by 
the  median  groove  and  raphe — these  are  the  eminences  over  the  facial 
genu  and  the  nucleus  common  to  both  facial  and  abducens  nerve. 
The  sensory  area  of  the  grey  floor  flanks  these  eminences  on  either  side 
like  walls,  diverging  from  them  at  a  somewhat  obtuse  angle,  the 
enclosed  space  being  bridged  over  by  the  cerebellum. 


22 


THE    PONS    VAKOLII. 


On  either  side  of  the  median  line  at  the  extreme  posterior  end  of 
the  raphe,  is  an  oval  cross-section  of  medulla  IJ  mm.  by  ^  mm.  in 
size,  sharply  defined  and  lying  between  the  grey  matter  of  the  lioor 
and  the  hindmost  series  of  arcuate  fasciculi  given  off  from  the  raphe; 
it  represents  the  root  of  the  facial  nerve  in  cross-section  at  its  curva- 
ture upwards,  otherwise  called  the  facial  g'enu.  From  its  neigh- 
bourhood medullated  fasciculi  sweep  in  a  wide  curve,  following  the 
inner  margin  of  the  grey  matter  as  far  as  the  sensory  area,  when  they 
pass  forwards  and  outwards  to  their  emergence  from  the  medulla, 
forming  in  this  latter  course  tlie  boundary  between  sensory  and  motor 
divisions.  In  the  sensory  division  outside  this  root  lies,  as  we  before 
indicated,  the  ascending"  trig'eminal  root.  The  sweep  of  the  facial 
in  its  course  beneath  the  grey  floor  encloses  a  large  and  important 
nucleus,  measuring  3  mm.  in  widest  diameter,  very  rich  in  cells  which 
are  multicaudate,  and  are   disposed  in  an  almost  circular  area;  from 

G.f. 


-Section  tbrousli  pons  ou  a  level  with  the  origin  of  the  great 
root  of  the  trigeminus. 


F.H,  Reticular  formation, 
s.o,  Superior  olivary  body. 
I',  Lemniscus  or  fillet. 
Py,  Pyramids. 

s.t.f,  d.t.f.  Superficial  and  deep  transverse 
fibres  of  the  pons. 


(?./,  Genu  of  facial  nerve. 
VII,  Root  fibres  of  facial. 

Vm,  Motor  nucleus  of  trigeminus. 

Va,  Ascending  root  of  trigeminus. 

R,  Restiform  tract. 

M.P,  Fibres  of  pons  varolii. 

p.l.b.  Posterior  longitudinal  fasciculus. 

the  outer  side  of  this  nucleus  emerge  root  fasciculi,  which  are  distinctly 
seen  to  join  the  facial  as  it  sweeps  forwards  round  the  nucleus  to  its 
point  of  emergence. 

On  the  other  hand,  from  the  posterior  and  inner  margin  of  this 
nucleus  other  fibres  emerge,  which  upon  the  inner  side  strike  forwards, 
becoming  gradually  more  divergent  from  the  raphe  in  sharply  defined 
fasciculi,  to  leave  at  the  lowest  border  of  the  pons  as  the  abducens 


ABDUCEXS-FACIALIS,    AND    UPPER    OLIVARY    BOUY,  23 

nerve  or  sixth  pair.    Tho  nucleus  itself  is  the  abducens-facialis, 

also  termed  the  pOSteriOP  or  SUpeHoP  facial  nucleus,  or  a;^'ain  the 
nucleus  of  the  sixth  nerve.  It  is  placed  in  communication  with 
the  cerebrum  by  means  of  the  tibr?e  rectre  of  the  raphe,  which  can  be 
readily  traced  as  the  most  posterior  of  the  arcuate  fibres  curving  first 
around  the  facial  genu  in  front,  and  then  passing  round  the  lower 
hemisphere  of  the  nucleus.  Considerably  in  front  of  the  abducens- 
facialis  nucleus,  and   in   the   motor  division   of  this  region,   lies  the 

inferior  or  anterior  facial  nucleus,  almost  parallel  with  the 

trigeminal  root,  but  separated  from  it  by  the  facial  emergent  fasciculi ; 
its  fibres  pass  backwards,  as  we  have  already  seen,  at  lower  levels  to 
arch  beneath  the  abducens-facialis  to  its  inner  and  posterior  aspect, 
and  thence  running  upwards  as  the  genu  of  the  facial,  again  bend 
around  its  upper  border  in  the  graceful  sweep  of  the  emergent  roots. 

The  Superior  Olivary  Body. — AVe  have  seen  that  this  body 
extends  from  the  lowest  border  of  the  2^ons  through  the  whole  tract 
of  origin  of  the  facial  nerve,  being  well-exposed  in  cross-sections,  lying 
between  the  inferior  facial  nucleus  and  the  emergent  root  fibres  of 
the  sixth  nerve.  The  transversely  disposed  fasciculi  lying  upon  its 
anterior  surface,  extending  from  the  decussation  at  the  raphe  to  ascend 
in  the  inferior  cerebellar  peduncle,  form  the  so-called  COrpuS  trape- 
ZOideS  which  becomes  exposed  superficially  in  animals  where  the 
dimensions  of  the  pons  are  greatly  reduced  with  the  diminished  supply 
of  fibres  reaching  the  medulla  from  the  crusta.  The  lemniscus  or 
fillet  lies  in  these  planes  to  the  inner  side  of  the  superior  olive, 
forming  the  pale-stained  area  of  truncated  triangular  outline  next 
the  raphe,  the  base  traversed  by  the  most  posterior  fasciculi  of  the 
pons  and  trapezoid  formation.  Into  the  fillet  at  higher  planes,  fibres 
of  the  upper  olive  pass  to  be  connected  with  the  central  grey  of  the 
lower  quadrigeminal  body,  the  testeS  ;  functionally  these  fibres  should 
be  regarded  as  centrifugal,  since  they  have  been  found  by  Flechsig 
to  degenerate  downivards  to  the  superior  olive, 

A  cerebellar  connection  is  established  between  these  bodies  and  the 
roof  nuclei  (nuclei  tecti)  of  the  middle  lobe  of  the  cerebellum ;  whilst 
other  fibres  pass  back  from  them  also  to  the  nucleus  of  the  sixth  and 
of  the  auditory  nerve,  as  well  as  to  the  lateral  columns  of  the  spinal 
cord.  Motor  impulses,  therefore,  emanate  from  this  body  to  the  sixth 
nerve  nucleus,  which  being  connected  by  decussating  fibres  with  the 
nucleus  of  the  opposite  motor  OCUli,  subserve  the  conjugate  deviating 
movements  of  the  eyeballs.  In  like  manner,  motor  impulses  to  the 
lateral  columns  of  the  cord  explain  the  associated  movements  of  the 
head  to  the  same  side. 

The  quadrigeminal  bodies,  on  the  other  hand,  Avhich  are  connected 


24  THE    PONS   VAROLII. 

with  the  optic  tracts,  transmit  stimuli  tlicnce  emanating,  to  the 
superior  olivary  l)odics  through  the  medium  of  the  fillet,  and  so  to  the 
oculo-motor  apparatus  of  the  sixth  and  third  nerves. 

We  have  ah'eady  seen  that  the  posterior  columns  of  the  cord  resolve 
themselves  through  the  intermediation  of  their  clavate  and  cuneate 
nuclei  into  the  restiform  tract  of  the  cerebellar  peduncle.  They  also 
by  the  anterior  sensory  decussation  of  a  portion  of  their  arcuate 
fasciculi  pass  upwards  on  either  side  of  the  median  raphe  as  the  fillet, 
and  thence  to  the  quadrigeminal  bodies.  This  portion  of  the  fillet, 
it  will  be  observed,  is  a  centripetal  or  sensory  tract,  so  that  the 
fillet  really  contains  systems  of  ascending  and  descending  fibres,  as 
is  indicated  also  by  the  results  of  lesions  affecting  the  tract. 

At  the  level  of  origin  of  the  sixth  and  seventh  cranial  nerves,  the 
central  grey  forming  the  floor  of  the  ventricle  is,  as  we  have  seen, 
extended  laterally,  shallow  from  before  backwards,  and  bounded  on 
either  side  by  the  restiform  tracts  :  as  we  ascend  to  a  higher  plane 
we  find  the  superior  cerebellar  peduncles  on  each  side,  which,  in  their 
descent,  restrict  the  lateral  extension  of  the  ventricle  and  its  investing 
grey  substance.  This  occurs  in  such  sections  as  are  cari'ied  through 
the  emergent  roots  of  the  fifth  nerve.  If  we  now  follow  the  ventricle 
towards  its  upper  angle,  we  find  with  the  convergence  of  the  superior 
peduncles  towards  the  quadrigeminal  bodies,  the  following  changes 
in  the  disposition  of  the  central  grey  : — First,  the  ventricle  becomes 
narrower ;  the  prominent  lips  of  the  grey  matter  become  more 
pronounced,  from  the  increase  in  the  thickness  of  this  formation ; 
and  at  the  same  time  the  ventricle  is  roofed  over  posteriorly  by  the 
anterior  medullary  velum.  The  nuclei  of  the  fifth  pair  alone 
of  all  the  cranial  nerves  characterise  this  plane. 

Higher  still,  we  come  upon  the  root  fibres  of  the  fourth  nerve 
which  decussate  across  the  aqueduct  posteriorly.  The  central 
grey  here  forms  two  notable  protruding  lips  on  cither  side  of  the 
mesial  line,  converting  the  aqueduct  into  a  Y-shaped  figure.  Progres- 
sive thickening  of  the  central  grey  substance  occurs  as  we  carry 
our  sections  through  the  posterior  and  anterior  quadrigeminal  bodies ; 
the  aqueduct  restricted  in  size  is  completely  surrounded  thereby, 
and  suff"ers  minor  alterations  in  its  outline  until  it  opens  up  into 
the  central  cavity  of  the  third  ventricle.  From  the  level  of  the 
crossing  of  the  fourth  nerve  upwards,  the  Y-shaped  grey  exhibits 
the  heak  of  the  Y  interposed  between  the  two  notable  bundles  of  the 
posterior  long^itudinal  fasciculus,  behind  which  we  may  con- 
tinuously follow  an  antcrlur  or  motor  column  of  grey  matter,  containing 
nerve  cells,  and  externally  a  lateral  or  sensory  column,  such  as  charac- 
terised  the   cranial   nerve  origins  in  the  lower  half  of  the  medulla. 


NUCLKI    AND    ROOT-FIBRES    OF   TRIGEMINAL.  25 

Betwixt  these  pianos  and  the  upper  roots  of  the  facial  nerve  lie  the 
emergent  fasciculi  of  the  fifth  nerve,  which,  in  accordance  with  its 
mixed  motor  and  sensorial  function,  also  assumes  a  lateral  site  of 
origin.     We  will  now  take  these  upper  cranial  nerves  seriatim. 

The  fifth  or  trigeminal  has  the  nucleus  of  origin  for  its  motor  root 
within  the  motor  area  of  the  pons  somewhat  similar  in  position  to  the 
nuclei  of  the  lateral  division,  which  at  lower  levels  sent  fasciculi  to 
the  mixed  system  of  nerves— the  so-called  nucleus  ambigUUS.  It, 
however,  lies  considerably  behind  this  nucleus  of  the  facial — the 
anterior  facial  nucleus — and  cannot  be  mistaken  for  it,  since  it  does 
not  present  the  same  convoluted  structure  ;  and,  moreover,  is  not  in 
the  mid  planes  of  section  of  the  upper  olive,  although  the  upper  end 
of  this  structure  is  still  seen.  Its  centric  fibres  pass  to  it  from  the 
median  raphe  where  they  decussate. 

The  origin  of  the  sensory  root  of  this  nerve  is  far  more  extensive. 
"We  have  throughout  the  whole  of  the  medulla  folloAved  up  in  our 
sections  the  ascending"  root  of  the  trigeminal,  noting  how  in 
the  lower  planes  of  the  medulla  the  vagus  and  glosso-pharyngeal,  and 
higher  up,  the  facial,  traversed  its  cross-section  near  their  points  of 
emergence,  and  now  find  it  lying  between  the  motor  nucleus  and 
the  restiform  tract  in  the  sensory  area  of  the  pons,  throwing  forwards 
its  root  fibres  to  emerge  between  the  transverse  fasciculi  of  the  pons. 
Below,  this  ascending  root  appears  to  end  in  the  tubei'cle  of  Rolando, 
and  so  would  seem  to  haA^e  a  close  connection  with  the  caput  COrnu 
pOSterioris.  A  median  root  is  described  as  originating  from  a 
nucleus  at  the  level  of  emergence  of  the  sensory  root,  in  contiguity 
with  the  ascending  root  and  the  motor  nucleus.  On  the  lateral 
margin  of  the  central  grey  around  the  aqueduct,  as  high  as  the 
anterior  quadrigeminal  body,  or  nates,  we  find  the  cross-section  of 
the  descending  root  of  the  fifth  nerve  with  very  characteristic  spherical 
or  vesicular  cells  lying  in  the  central  grey  upon  the  inner  side  of 
the  root  fasciculi.  Both  cells  and  descending  fasciculi  become  more 
conspicuous  at  lower  levels,  and  the  latter  extend  to  the  level  of  the 
exit  of  the  sensory  root,  where  they  join  it  to  emerge  from  the  pons. 
Internal  to  this  descending  root  is  a  series  of  deeply  pigmented  nerve 
cells,  forming  the  substantia  ferruginea,  which  is  seen  through  the 
grey  floor  of  the  ventricle  at  the  site  named  the  loCUS  COeruleus. 
From  these  cells,  according  to  Meynert,  pass  root  fibres  to  the 
opposite  trigeminal  root  (sensory  trunk),  Avhich  in  their  coui'se 
surround  and  traverse  the  posterior  longitudinal  fasciculus, 
decussate  at  the  posterior  extremity  of  the  raphe,  and  thence  following 
out  the  anterior  margin  of  the  central  grey,  arch  into  the  opposite 
sensory  root.     Associated  Avith  these  latter  fibres  are  described  others 


26  THE    PEDUNCULAR    REOION. 

whicli  issue  from  the  median  raphe  posteriorly,  and  after  decussation 
terminate  in  the  sensory  root  likewise.  Lastly,  a  cerebellar  roOt 
is  described  by  some  authorities. 

In  the  motor  column  of  the  central  grey,  lying  immediately  behind 
the  posterior  longitudinal  fasciculus,  on  either  side  of  the  median  line 
and  beneath  the  nates,  is  a  well-defined  grouping  of  cells,  which, 
however,  usually  presents  an  apparent  segmentation  into  distinct 
clusters.  These  nerve  cells,  commencing  as  high  up  as  the  posterior 
commissure,  are  at  first  somewhat  scattered,  but  assume  a  more 
compact  form  as  they  run  backwards  towards  the  upper  half  of  the 
testes,  in  which  region  they  appear  lodged  in  a  hollow  of  the  posterior 
wall  of  the  longitudinal  fasciculus.  This  nuclear  column  represents 
the  origin  common  to  the  OCUlO-motor  (third)  and  the  trochlearis 
(fourth)  nerves;  the  upper,  scattered,  segmented  portion  is  the  nucleus 
of  the  third  more  especially ;  the  lower  compact  segment  lying  at  the 
junction  of  the  two  quadrigeminal  bodies  is  the  nucleus  of  the  fourth 
nerve.  Both  are  believed  to  receive  their  centric  fibres  through  the 
median  raphe,  those  of  the  third  nerve  decussating  ere  they  reach 
their  nucleus. 

The  root  fibres  of  the  third  nerve  emerge  in  a  series  of  arched 
fasciculi  directed  forwards,  with  their  concavities,  for  the  most  part, 
looking  towards  the  raphe ;  and  in  their  course  traverse  and  partially 
encircle  the  red  nucleus  of  the  tegmentum,  which,  as  we  shall  see 
further  on,  lies  on  either  side  of  the  raphe  above  the  plane  of  their 
decussation. 

The  root  fibres  of  the  fourth  nerve  take  a  much  more  circuitous 
course,  running  backwards  instead  of  forwards  to  their  point  of 
emergence ;  an  anomaly  accounted  for  by  Dr.  Ross  by  the  decussation 
of  the  upper  cerebellar  peduncles  which  occurs  in  the  region  of  the 
testes  severing  the  nuclear  segment  of  the  fourth  from  that  of  the 
third  nerve,  and  so  "  compelling  the  former  to  seek  its  destination  by 
an  independent  route."*  Commencing  at  the  junction  of  the  nates 
and  testes  from  this  compact  segment,  the  root  fibres  of  the  fourth 
nerve  curve  around  the  outer  zone  of  the  central  grey  matter  to  reach 
the  anteriormeduUary  velum,  where  they  bound  the  aqueduct  posteriorly. 
To  reach  this  point  which  lies  below  the  testes,  the  root  fibres  must 
necessarily  have  traversed  the  full  extent  of  the  former,  passing 
obliquely  backwards  and  downwards  to  the  valve  Of  Vieussens. 
Crossing  in  the  substance  of  this  valve  the  fibres  of  opposite  sides 
decussate,  presenting  another  anomaly — since  none  of  the  other 
cranial   nerves   (except  the   optic   tracts)   decussate  on    the   distal   or 

*  Diseases  of  the  Nervous  System,  vol.  ii. ,  p.  44. 


THE    MESENCEPHALON.  27 

peripheral  side  of  their  nuch'i  of  origin,  but  iuvarialjly  ou  tlidr 
proximal  or  centric  side, 

THE   MESENCEPHALON. 

Upon  the  most  casual  examination  of  the  cereLro-spinal  axis,  one  is 
struck  forcibly  by  the  simple  arrangement  and  solidarity  of  the  spinal 
as  compared  with  the  remaining  portion  or  upper  end  of  this  system — 
the  gradual  increasing  complexity  of  the  grey  and  medullated  tracts  of 

the  after-  and  hind-brain,  the  so-called  medulla  oblong-ata  and 

pons,  and  the  uniform  divergence  of  these  tracts  at  higher  and  still 
higher  levels  :  both  gangliated  masses  and  medullated  systems  alike 
severing  their  alliance,  and  diverging  on  either  side  in  correspondence 
with  the  severance  of  the  uppermost  system  into  the  two  great 
hemispheric  masses.  As  we  rise  step  by  step  from  medulla  to  pons, 
from  pons  to  corpora  quadrigemina,  thence  to  the  thalamic  region,  and 
lastly  to  the  corpora  striata  of  the  prosencephalon,  we  find  the 
grey  masses  becoming  larger  and  more  widely  separated ;  whilst  the 
medullated  tracts,  in  like  manner,  diverge  and  empty  themselves  at 
different  levels  into  the  several  ganglionic  masses — in  all  cases,  pro- 
bably, to  take  a  fresh  departure  to  their  final  destination  in  the 
cerebral  cortex. 

Leaving  for  the  time  the  more  consolidated  tracts  of  the  epence- 
phalon   or  hind-brain,     and    concentrating    our    attention    on   the 

mid-brain— i.e.,  the  corpora  quadrig-emina  with  the  crusta — 

and  the  central  grey  common  to  the  whole  cerebro-spinal  system,  we 
find  that  the  crura  cerebri,  athwart  which  the  quadrigeminal  bodies 
are  placed,  have  two  distinct  tracts  of  wholly  difterent  destiny — the 
tegmentum  and  crusta,  best  seen  in  transverse  section. 

The  former  occupies  the  posterior  and  inner  region  of  the  crura,  and 
partly  empties  itself  into  the  superjacent  quadrigeminal  bodies,  and  in 
part  into  the  optiC  thalami  :  whereas  the  latter — the  crusta,  lying 
in  front  and  to  the  outer  side  of  the  tegmentum — becomes  more  and 
more  divergent  from  its  fellow  of  the  opposite  side  as  it  courses 
upwards,  passes  in  part  into  the  basal  ganglia,  and  in  part  expands 
into  a  wide-spread  fan  of  fibres  for  distribution  to  the  extensive 
cortex  of  the  cerebral  hemispheres.  Thus  we  observe  that  the  medul- 
lated tracts  of  the  tegmentum  and  crusta  in  turn  empty  themselves 
into  the  several  ganglionic  masses  met  with  from  time  to  time — the 

quadrigeminal  bodies,  pineal  gland,  thalami  optici,  striate 

bodies,  and  cortex  cerebri.  It  is  important  that  the  student 
understand  that  the  termination  of  the  fibres  upwards  occurs  in  grey 
masses  placed  at  different  relative  levels,  answering  to  tlie  position  of 


28  THE    MESENCEPHALON'. 

the  liind-braiii,  the  mid-brain,  the  inter-ljrain,  and  the  fore-brain : 
and  he  should  gain  a  clear  conception  of  each  individual  tract,  so  far 
as  at  present  known,  to  its  terminus  in  a  grey  centre.  To  return  to 
the  meSGncephalon,  the  hind  and  inner  portion  of  the  crura  forms, 
as  "sve  said,  the  tegmentum,  and  on  this  structure  rest  the  quadri- 
geminal  bodies  and  thalami ;  on  the  other  hand,  if  we  follow  the  crusta 
upwards,  as  exposed  at  the  base,  we  find  that  each  crusta  diverges 
more  and  more  until  it  meets  the  emljracing  optiC  tractS,  which 
at  this  part  of  the  base  define  the  boundary  between  mesencephalon 
behind  and  thalamencephalon  in  front.  At  this  point  each  crusta 
plunges  deeply  into  the  brain,  disappearing  between  thalamus  and 
lenticulaP  nucleus,  and  passes  up  as  a  compressed  medullated  tract 
between  the  basal  ganglia,  emerging  above  their  level  as  a  wide-spread 
fan  of  fibres  to  the  hemispheres.  In  this  course,  where  they  form  a 
divisional  wall  between  the  large  ganglia,  they  constitute  what  is  called 
the  internal  capsule,  the  formation  of  which  merits  careful  study. 

If  we  imagine  the  crusta  as  seen  from  the  base  pass  up  unchanged 
in  direction  into  the  internal  capsule,  we  shall  then  perceive  that  the 
latter  would  take  a  direction  sloping  obliquely  upwards  and  outwards, 
presenting  two  surfaces — a  lower,  looking  downwards,  outwards,  and 
backwards,  roofing  over  the  lenticular  nucleus,  and  corresponding  and 
continuous  with  the  superficial  surface  of  the  crusta  as  far  as  the  pons; 
and  an  upper  surface,  upon  which  the  thalamus  rests,  corresponding  to 
the  deeper  portion  which  lies  adjacent  to  the  tegmentum.  It  would 
also  present  two  free  borders — the  internal  or  mesial,  and  the  external 
or  posterior.  In  the  further  expansion  of  this  belt  of  fibres,  the  inner 
or  mesial  suffers  displacement  through  the  intrusion  in  mesial  planes 
of  the  head  of  the  caudate  nucleus,  whereby  the  anterior  portion 
of  the  capsular  fibres  is  thrust  outwards,  forming  a  sharp  bend  or 
"knee"  with  the  posterior  division.  Thus  we  observe  that  the  internal 
capsule  is  a  stratum  of  fibres  with  a  concavity  looking  downwards  and 
outwards,  arching  as  a  roof  over  the  lenticular  nucleus,  and  forming  a 
medullated  bed,  upon  the  anterior  segment  of  which  rests  the  caudate 
nucleus,  and  upon  the  posterior  margin  of  which  rests  the  thalamus. 

If  now  we  examine  these  ganglionic  masses  from  above,  as  seen 
within  the  lateral  ventricles,  it  is  evident  that  the  long  axis  of  each 
is  similarly  disposed — i.e.,  from  the  mesial  line  obliquely  backwards 
and  outwards ;  that  the  outermost  of  these  masses,  the  two  caudate 
nuclei,  have  their  large  pyriform  head  directed  anteriorly,  whilst  their 
attenuated  tail-like  process  appears  pressed  outwards  by  the  narrow 
anterior  pole  of  the  wedge-shaped  thalami.  In  like  manner  the  latter, 
which  have  their  broad  extremity  hindmost,  are  also  pressed  out- 
wards behind  by  the  intervening  quadrigeminal  and  g-enlculate 


CORPORA   QUADRIGEMINA   AND   TIIALAMI. 


29 


bodies.  Tliese  three  important  structures— the  corpora  quadri- 
gcniina,  thalami,  and  caudate  nuclei— which  represent  the  tlirce 
divisions   of    the    mesencephalon,    diencephalon,    and   partly   of  the 


Septum  lucidum 
Columnae  fornicis 

Corpus  striatum 
Stria  tenuiualis. 
Thalamus  opticus. 


^lacliiuni  cr-Tiiiui 
tivum  anticum. 
Pedunculus  cerebri 


["  ad  corpora 
quadrige- 

ad  meduUam 
oblongatain. 


Cius 

eeiebelli 


.  ad  pontem. 


Cornu  anticum. 


Caput  nuclei  caudatL 

—  Capsula  interna 
(anterior  limb). 

Capsula  externa. 

Island  o{  Reil. 

— ■  Nucleus  lentiformis. 
— .  Cla'istrum. 


— r-  Capsula  interna 
K-ia  (posterior  limb). 
'•'^'J Thalamus  opticus. 


Corpus  genicula- 
tum  mediale. 


Caudate  nucleus 


Hippocampu*. 


y Calcar  avia. 


Funiculus  gracilis. 

Fig.  6.-Horizoutal  section  titrough  liemisplieres,  the  right  at  a  deeper 
level  than  the  left, 

prosencephalon,    as    before    indicated,    rest   upon    and     embrace   the 
tegmental  and  crustal  divisions  of  the  cerebral  peduncle. 

On   the  other  hand,   the   outer  division   of  the   striate   body— the 


30  Tin:    MESENCEPHALON. 

It'iitiuular  nucleus — has  its  base  directed  forwards  and  outwards 
parallel  Avith  the  insula,  whilst  its  wedge-shaped  apex  is  directed 
backwards  and  inwards  towards  the  base — its  upper  surface,  convex 
from  before  backwards,  being  adapted  to  the  concavity  of  the  internal 
capsule.  The  general  relationships  of  the  internal  capsule  are  well 
seen  in  horizontal  sections  carried  across  the  hemisphere  at  succes- 
sively higher  levels.  Kear  the  base  it  forms  a  quadrilateral  section 
directed  from  within  outwards  and  separating  the  tegmentum  from 
the    lenticular    nucleus,    having   immediately    behind    it    the    locUS 

nig'ep,  and  parallel  with  it  in  front  the  anterior  commissure  as  it 

passes  outwards  through  the  lenticular  nucleus.  It  will  be  recalled 
that  the  crust,  ere  it  disappeared  into  the  depths  of  the  hemisphere  at 
the  base,  was  bounded  by  the  broad  optic  tracts :  these  are  destined  to 
terminate  in  the  external  g'eniculate  body,  and  at  a  slightly 
higher  plane  these  bodies  appear  immediately  behind  the  extremity  of 
the  internal  capsule  as  seen  in  transverse  section.  At  a  higher  level, 
however,  above  the  anterior,  and  through  the  plane  of  the  middle 
commissure,  the  anterior  portion  is  bent  outwards,  forming  an 
obtuse  angle  or  "  knee,"  so  that  a  horizontal  section  through  both 
hemispheres  at  this  level  represents  both  internal  capsules  as  an 
X-shaped  figure  with  two  anterior  and  two  j^osterior  segments  (tig.  6). 
In  the  lateral  angle  of  this  X  the  wedge  of  the  lenticular  nucleus 
insinuates  itself;  between  the  anterior  segments  of  the  X  the  nuclei 
caudati  appear ;  whilst  the  posterior  segments  include  the  optic 
thalami.  At  the  central  junction  of  these  limbs,  we  find  the  fornix 
out  across. 

Lastly,  turning  our  attention  again  to  the  base  of  the  brain,  Ave  see 
that  the  divergence  of  the  peduncles,  as  they  ascend,  leaves  between 
them  in  the  middle  line,  first,  the  posterior  perforated  space — 
a  bridge-like  extension  of  grey  substance  at  the  angle  between  both 
peduncles,  perforated  by  numerous  vessels  which  enter  the  base  of  the 
thalamus  at  this  point ;  and  from  which  white  fibres  emerge  and 
course  round  the  upper  margin  of  the  pons — the  taenia  pontis.  In 
front  of  the  perforated  space  are  two  rounded  bodies — the  corpora 
albicantia — round  which  the  pillars  of  the  fornix  turn  ;  and  from 
these  bodies  a  thin  grey  lamella  stretches  forwards  as  far  as  the  optic 
commissure,  forming  the  floor  of  the  third  ventricle  :  from  its  floor  a 
hollow  tube — the  infundibulum — descends,  to  which  is  attached  the 

pituitary  body. 

Having  thus  far  defined  the  limits  of  crusta  and  internal  capsule, 
we  can  the  more  clearly  appreciate  the  course  and  distribution  of  their 
fibres.  Since  the  crusta  represents  the  continuation  upwards  of  the 
pyramidal  tract  of  the  cord,  it  must  receive  a  considerable  rein- 


CONDUCTIN<i    TRACTS    OF    CRUSTA. 


31 


forcenieiit  of  fibres  within  the  pons  to  account  for  the  much  larger 
size  which  the  crusta  bears  to  the  corresponding  anterior  pyramid  of 
the  medulla.  An  examination  of  the  pyramidal  tracts  and  crusta  in  a 
nine  months'  embryo  gives  us  most  valuable  information  respecting 
the  origin  of  the  fibres  found  therein.  In  the  pyramids  the  outer 
portion  of  the  tract  consists  of  distinctly  medullated  fibres ;  the  inner 
and  anterior  of  non-medullated  fibres ;  and  an  intervening  portion 
contains  a  mixture  of  both.  In  the  pons  a  similar  distribution  of 
these  fibres  is  seen:  whilst  higher  up  still  in  the  crusta,  the  non- 
medullated  fibres  occupy  the  inner  third;  the  medullated  fibres,  the 
middle  third;  whilst  the  admixture  of  both  is  found  behind  and 
between  the  two  former.  This  embryological  dissection  maps  out  three 
distinct  systems  of  fibres  which  have  received  the  respective  names  of 

(a)  the  fundamental  or  medullated;  (b)  the  mixed  system; 
(c)  the  accessory  or  non-medullated  system. 

Still  further  outwards,  occupying  the  outer  fourth  of  the  crusta, 
just  beyond  the  fundamental  system,  are  found  the  fibres  which 
represent  the  continuation  upwards  to  the  hemispheres  of  the  sensory 
columns  of  the  cord. 

If  we  now  trace  these  tracts  upwards  into  the  internal  capsule,  we 
find  that  the  accessory  or  innermost  passes  up  along  the  anterior 
segment  of  the  capsule ;  the  mixed  occupies  in  its  ascent  the  anterior 
third  of  the  posterior  segment,  the  fundamental  the  middle  third  of  the 
same  segment;  whilst  the  posterior  third  or  outermost  part  of  the 
capsule  is  occupied  by  the  sensory  tract  of  the  peduncles  :  or  tabulated 
also  with  reference  to  their  distribution,  thus  : — 


Tracts. 


Accessory  Tract, 


Position  in 
Ckusta. 
Inner  third, 


In  Intkrnal 

Capsule. 

Anterior  segment, 


Mixed  Tract,  Behind  and  between 

Accessory  and 
Fundamental, 

Fundamental  Tract,  Middle  third, 


Outer  fourth, 


Posterior  segment, 
Anterior  third. 

Posterior  segment, 
Middle^third, 


Sensory  Tract, 

The  above  table  reads  as  follows  : — The  accessory  tract  occupies  the  inner  third 


Do.,  do.. 

Posterior  third. 


Cortical  Termini. 

Third  frontal  gyrus 
posteriorly.  As- 
cending frontal 
and  parietal  gyri 
at  their  lower 
end. 

Second  frontal  and 
middle  portion  of 
central  g3'ri. 

First  frontal  pos- 
teriorly. Upper 
end  of  central 
gyri;  paracentral 
and  parietal  gyri. 

Tempore  -  occipital 
regions. 


32  Till:    MESKXCKl'llALOX. 

of  tlie  crusta,  passes  up  the  anterioi-  segment  of  internal  capsule,  and  terminates 
in  tlic  cortex  of  the  tliinl  frontal  and  lower  end  of  ascending  frontal  and  parietal 
gyri — and  so  for  the  remaining  tiaets. 

The  student  must  bear  in  mind  that  the  crust  of  the  peduncle 
contains  a  very  large  system  of  fibres,  and  that  the  tracts  above 
described  by  no  means  represent  the  whole  series.  Thus  each  crusta 
includes,  not  alone  tracts  of  the  pyramidal  fibres,  but  the  sensory 
tracts  of  the  cords — fibres  to  the  thalamus  and  caudate  nucleus,  itc. 
The  tracts  we  have  now  traced  have  no  connection  with  the  basal 
ganglia :  they  pass  between  the  lenticular  nucleus,  thalamus,  and 
caudate  nucleus  uninterruptedly  to  their  cortical  termini.  Thus,  as  Ave 
have  seen,  the  pyramidal  tract  extends  uninterruj^tedly  between  the 
cortex  of  the  central  g'yri  and  their  immediate  neighbourhood,  and 
the  motor  cells  of  the  anterior  COrnua  of  tlie  cord  at  different  levels 
throughout  its  course :  and  this  pertains  both  to  the  motor  or  pyramidal 
and  to  the  sensory  tracts.  It  is  obvious  that  the  body  and  lower 
extremities  have  the  least  specialised  movements,  just  as  the  arm  and 
hand  and  the  muscles  of  articulate  speech  are  excessively  specialised; 
and,  that  whereas  the  accessory  group  of  fibres  which  supply  the  latter 
chiefly  have  to  deal  with  vei-y  complex  and  specialised  co-ordinations, 
the  muscles  being  very  numerous,  but  relatively  very  small  in  size :  the 
fundamental  group  which  sujDply  the  large  muscles  of  the  limbs,  and 
especially  of  the  lower  extremity,  have  to  deal  with  simple  massive 
movements,  the  musculature  being  correspondingly  bulky  and  less 
specialised.  We  see,  therefore,  that  the  accessoiy  group,  arising  from 
the  cortex  at  the  lower  end  of  the  central  gyri,  pass  chiefly  to  the 
spinal  levels  of  the  face,  mouth,  and  hands,  whilst  the  greater  bulk  of 
the  fundamental  group  arising  at  the  upper  end  of  the  centi'al  gyri 
extend  as  far  as  the  lumbar  enlargement  for  the  musculature  of  the 
legs.  Hence  the  former  constitute  comparatively  sliort  loops,  and 
supply  many  tliougli  small  muscles ;  the  latter  constitute  very  lengthy 
loops,  and  supply  the  largest  muscles  of  the  frame.  The  latter 
originate  in  the  largest  nerve  cells  discoverable,  the  former  or 
accessory  in  cells  of  greatly  reduced  dimensions.  The  fibres  of  the 
sensory  columns  of  the  cord,  according  to  Meynert,  undergo  a  decussa- 
tion upon  a  level  with  the  decussation  of  the  crossed  jDyramidal  fibres 
by  arching  forwards  around  the  central  grey  column,  and  after  decus- 
sation passing  up  on  the  outer  side  of  the  anterior  pyramid  to  the 
hinder  third  of  the  internal  capsule,  Avhen  they  suddenly  turn  back, 
and  are  distributed  to  the  occipital  and  temporo-sphenoidal  lobes. 
As  before  stated,  they  have  no  connection  with  tlie  thalamus  or 
lenticular  nucleus.  So  far  for  the  direct  sensory  and  motor  fasciculi 
of  the  crusta   and  internal   capsule.     The  internal  capsule,  however. 


CONSTITUTION    OF    INTERNAL    CAPSULE.  33 

includes  several  otliei'  systems  of  fibres,  of  which  the  following  are  the 
more  readily  followed  out : — 

(rt.)  Fibres  to   the   cortex   from    the    outer  surface   of  the   optic 

thalamus. 
(b.)  Fibres  to  the  cortex  from  the  outer  surface  of  the  caudate 

nucleus, 
(c.)   Fibres  to   the   cortex  from   the   upper  and  inner  surface   of 

lenticular  nucleus.     (Denied  by  Wernicke.) 

(a.)  Thalamic  radial  fibres  given  off  from  the  whole  length  of  the 
outer  surface  of  the  thalamus  radiate  forwards,  outwards,  and  back- 
Avards ;  the  anterior  radiations  towards  the  frontal  lobe  ;  the  median, 
outwards  to  the  parietal ;  and  the  posterior,  arching  backwards  and 
upwards  to  the  occipital  lobe.  The  latter  or  posterior  is  a  very 
important  formation,  and  is  separately  distinguished  as  the  radia- 
tions of  Gpatiolet :  it  serves  as  the  means  whereby  the  several 
roots  of  the  optic  nerve,  which  terminate  in  the  quadrigeminal, 
geniculate  bodies,  and  thalamus  are  connected  with  the  OCCipital 
cortex.  These  optic  radiations  pass  through  the  posterior  third  of 
the  internal  capsule,  and  are  consequently  brought  in  close  relation- 
ship to  the  sensory  peduncular  tract  already  described  as 
occupying  this  position. 

(6.)  In  like  manner,  fibres  radiate  from  the  outer  surface  of  the 
caudate  nucleus  to  reach  the  cortex  in  planes  internal  to  and  above 
those  of  the  thalamus. 

(c.)  Fibres  arise  from  the  upper  and  inner  surface  of  the  lenticular 
nucleus  to  interlace  with  the  fibres  of  the  internal  capsule. 

(d.)  A  system  of  fibres  has  been  assumed  by  Flechsig  to  pass  con- 
tinuously through  the  red  nucleus  of  the  tegmentum  and  thalamus 
into  the  internal  capsule,  to  be  distributed  along  with  the  fibres  of  the 
pyramidal  tract  to  the  region  of  the  Rolandic  fissure.  By  this 
means  a  crossed  connection  would  be  established  between  the  central 

gyri  and  the  cerebellum. 

(e.)  Fil)res  from  the  olfactory  bulb,  after  decussation  in  the 
anterior  commissure,  are  also  believed  by  Meynert  to  join  the  optic 
radiations  of  Gratiolet,  to  be  distributed  to  the  occipital  and  temporo- 
sphenoidal  cortex. 

We  have  seen  how  those  peduncular  fibres  forming  the  crusta 
diverge  and  enter  the  hemisphere  as  the  internal  capsule,  supporting 
upon  its  upper  surface  the  caudate  nucleus  and  thalamus,  and  receiv- 
ing into  its  concavity  below  the  wedge-shaped  mass  of  the  lenticular 
nucleus,  whose  apex  contributes  a  mass  of  fibres  to  the  formation  of 
the   crusta.     If  we  now  imac;ine  a  lamella  of  fibres  spread  over  the 

3 


34  THE    MESENCKPIIALON. 

broad  base  or  outer  aspect  of  this  wedge  to  pass  downwards  beneath 
the  lenticular  nuck'us  towards  its  apex,  and  there  meeting  the  crusta, 
whose  fibres  it  crosses  transversely  to  its  inner  side :  we  have  an 
arrangement  which,  from  the  insula  and  temporal  regions  of  the  brain, 
passes  to  the  base,  as  a  sort  of  sling-like  loop  supporting  these 
ganglionic  masses,  and  binding  them  and  the  peduncles  together. 
Such  an  arrangement  is  represented  by  the  external  capsule  and  its 
continuation  at  the  base,  where  it  is  termed  the  ansa  peduncularis 
of  Gratiolet  or  SUlDStantia  innominata  of  Pail ;  and  a  portion  of 
which  crossing  the  crusta  to  its  inner  side  is  named  the  COUar, 
fillet,   or  loop  of  the  CPUS. 

This  important  formation  of  the  ansa  peduncularis  consists  of  four 
systems  of  fibres,  according  to  the  statement  of  Meynert.  They 
arise  from  the  under  surface  of  the  lenticular  nucleus,  from  a  ganglion 
lying  in  this  position,  and  Irom  the  cortex  of  the  sylvian  fissure, 
upper  and  temporal  margin  of  the  insula.  The  capsular  portion  of 
the  ansa  has  no  organic  connection  with  the  base  of  the  lenticu- 
lar wedge  over  which  it  spreads,  so  that  it  can  be  readily  separated, 
and  the  latter  enucleated  by  the  handle  of  the  scalpel.  Its  fibres, 
which  arise  from  the  cortex  of  the  insula  and  upper  margin  of 
the  sylvian  fissure,  necessarily  pass  to  it  through  the  claustral 
formation  ;  and  then,  forming  the  compact  lamella  of  the  external 
capsule,  converge  to  the  fasciculi  at  the  base  of  the  lenticular  nucleus, 
which  we  referred  to  as  the  ansa.  At  this  point  it  is  crossed 
superficially  by  the  anterior  commissure,  which  has  to  be  removed  to 
expose  it  in  its  entirety.  The  deepest  layer  of  the  ansa  peduncularis 
takes  its  origin  from  fibres  issuing  at  the  base  of  the  lenticular  nuchnis 
— from  those  concentric  lamella;,  the  laminae  medullares.  The 
fasciculus  completely  crosses  the  crusta  parallel  to,  and  immediately 
in  front  of,  the  optic  tracts,  and  passing  to  the  inner  or  median 
border  of  the  crusta,  forms  the  innermost  series  of  fibres,  here  destined 
to  pass  back  along  the  raph§  to  the  central  grey  sul)stance,  where 
they  terminate  after  decussation  in  the  nucleus  of  Origfin  of  the 
oculo-motor  and  trochlear  nerves  within  the  nates.  The  second 
layer  originating  in  fibres  from  the  cortex  of  the  upper  margin  of  the 
sylvian  fissure,  the  temporal  lobe  and  the  cortex  of  the  insula,  is 
interrupted  in  an  elongated  ganglion  at  the  base  of  the  lenticular 
nucleus.  From  this  ganglion  fresh  fibres  proceed  at  first  parallel  to 
the  course  of  the  rest  of  the  ansa,  but  then  suddenly  bending  back- 
wards and  upwards,  pursue  their  further  course  just  within  the  grey 
substance  of  the  third  ventricle,  forming  the  well-marked  bundle  of 

medullated  fibres  known  as  the  posterior  longitudinal  fasciculus, 

which  may  possibly  be  traced  down  into  the  spinal  cord  as  the  most 


AXSA    PEDUNCULARIS. 


35 


posterior   of  the  fibres  of  the  anterior  column   in  front  of  th(j   grey 
comuiissure  of  the  coi'd. 

The  third  layer  of  the  ansa  arises  from  the  sylvian  foSSa  and 
the  cortex  of  the  temporal  lobe,  runs  parallel  to  the  above-mentioned 
fasciculi  at  the  base  of  the  lenticular  nucleus ;  and  then  turning 
upwards  into  the  thalamus,  forms  a  brush-like  radiation  of  its  fibres 
far  back  into  the  interior,  constituting  the  so-called  inferior  peduncle 
of  the  thalamus.  A  fourth  layer  of  the  ansa  which  overlies  the 
latter  joins  the  stratum  ZOnale,  or  capsular  investment  of  the 
thalamus.  This  substantial  belt  of  the  ansa  firmly  binds  together 
the  region  of  the  operculum  and  island  to  the  central  structures  at 
the  base  of  the  brain,  forming  a  complete  sling  around  the  lenticular 
wedge,  consisting  of  a  series  of  loops,  the  deepest  of  which  connects 
the  base  of  the  lenticular  body  to  the  motor  nuclei  in  front  of  the 
aqueduct ;  the  others  having  a  more  lengthened  course  from  the 
cortex  to  the  anterior  column  of  the  spinal  cord,  or  blending  in- 
timately with  the  structures  of  the  optic  thalamus  and  its  capsular 
investment.     We  may  tabulate  the  fibres  of  the  ansa  as  follows  : — 


Ansa  Peduncularis  (Gratiolet)  or  Substantia  Ixnomixata  (ReU). 

Layers.  Origin.  Destination. 

First  or  deepest,  and  ex-     Laminfe    medullares    of    Motor   nuclei    of    third   and 


tending  furthest  back.         lenticular  nucleus. 


trochlear. 


Second  or  middle  layer,*     Ganglion   of  loop  ;  con-     As  posterior  longitudinal  fas- 


extending  furtherback 
than  third  and  fourth 
layers. 


nected  centrally  with 

cortex  of    operculum, 

insula,  and    temporal 
lobe. 


ciculus   down  the  anterior 
columns  of  spinal  cord. 


Third,    more   superficial     Sylvian  fossa,    temporal     As  inferior  peduncle  of  optic 
and  anterior.  lobe.  thalamus ;    passes   to    pos- 

terior commissure. 


Fourth,  most  superficial     Cortex  of  temporal  lobe.     Stratum  zonale  of  optic  thala- 
and  anterior.  mus,    bounds    and    unites 

with  ganglion  of  Habenula 
and  passes  on  to  posterior 
commissure. 

Dissection. — Place  the  brain  with  the  base  uppermost,  having  carefull}' 
removed  the  membranes  and  the  lai'ge  vessels.  Remove  with  tlie  blade  a  sliallow 
horizontal  slice  from  one  of  tlie  temporo-sphenoidal  lobes  so  as  to  pa^s  through  the 
hook  of  the  uncinate  gyrus  ;  this  lays  bare  the  section  of  the  pes  hippo- 
campi,   and    the    amygdaloid    nucleus.      Pass    the    handle    of   tlie    scalpel 

*  Greyish  in  colour  and  softer  than  the  rest. 


3G  THE    MESENCEPHALON, 

vertically  tlirough  tlie  medullary  stranils  outside  the  pes  — it  enters  the  extremity 
of  the  descending  liorn  of  the  lateral  ventricle.  Carry  an  incision  along  tlie 
floor  in  a  somewhat  curved  direction,  backwards  and  outwards,  along  the  whole 
length  of  the  occipito-temporal  gyri.  This  exposes  the  descending  cornu  throughout 
its  extent,  and  the  worm-like  GOrnU  ammonis  is  seen  descending  from  above 
to  terminate  at  the  pes.  The  tail  of  the  caudate  and  lenticular  nuclei  are 
now  seen  along  the  roof  of  the  cornu,  and  a  white,   glistenin:.',    narrow  Ijand  of 

fibres  curves  downwards  towards  the  amyg'dala— the  tsenia  semicirculapis. 

Upon  raising  up  the  inner  border  of  the  uncinate  gyrus,  we  expose  the  optic  tracts 
arching  backwards  over  the  crusta,  and  terminating  in  the  two  elevations  of 
the  corpora  geniculata,  externa  and  interna,  beyond  which  the  pulvinaP  of 
the  thalamus  projects.  In  front  of  the  optic  tracts  the  crusta  has  dis- 
appeared in  the  depths  of  the  hemisphere,  and  we  see  here  the  triangular  floor 
of  the  anterior  perforated  space  bounded  by  the  delicate  white  roots  of  the 
olfactory  nerves.  Drawing  the  optic  nerves  backwards  we  expose  the  delicate, 
almost  translucent  grey  lamina  forming  the  floor  of  the  fifth  ventricle,  bounded 
by  the  two  white  peduncles  of  the  COPpUS  callOSUm,  which  at  this  juncture 
probably  tears  across,  revealing  a  broad  white  fasciculus,  the  antCPiOP  COmmis- 
SUPe,  crossing  from  one  to  the  other  hemispliere. 

Upon  gently  drawing  apart  the  divergent  crura  cerebri  in  front, 
a  dark  line  is  apparent,  running  the  whole  length  of  its  mesial 
aspect  at  a  greater  depth  than  the  innermost  fasciculi  of  the  crusta. 
This,  upon  dividing  the  crura,  is  seen  to  he  the  inner  margin  of  a 
dark  pigmented  body,  of  lenticular  section,  the  Substantia  nig'Pa 
of  Soemmering,  which  forms  a  distinct  boundary  wall  betwixt  the 
crusta  in  front  and  the  tegmentum  behind  :  it  extends  from  the 
level  of  the  corpora  albicantia  as  far  as  the  upper  border  of  the 
pons.  We  shall  refer  more  minutely  to  its  relationships  when 
studying  transverse  sections  of  this  region.  Immediately  behind 
lie  the  tegmentum  and  the  large  ganglia  of  the  mid-lirain  or  quadri- 
geminal  bodies. 

We  can  best  study  this  posterior  division  of  the  mesencephalon 
by  first  examining  the  external  configuration  and  connections  of 
these  ganglia,  and  subsequently  following  the  course  of  their  fibres, 
and  next  by  studying  the  relative  position  of  the  fasciculi  as  seen 
in  transverse  section  at  different  levels.  If  now  we  so  separate 
the  occipital  lobes  of  the  hemispheres  as  to  expose  these  bodies  to 
view  from  above,  they  appear  in  a  mid  position  between  the  two 
divergent  cushions  of  the  thalamus,  overriding  the  cerebral  peduncles 
in  the  form  of  two  pairs  of  tubercles — an  upper  and  a  lower, 
each  oval  in  form,  the  upper  pair  the  larger  and  darker  in  colour, 
both  having  their  long  axis  disposed  transversely.  Both  pairs  of 
tubercles  extend  upwards  and  forwards  an  arm,  which  is  really  a 
connection  for  the  cerebral  cortex,  and  spreads  upwards  as  COPOnal 
radiations  :  each  pair  in  like  manner  sends  downwards  a  medullated 


LEMNISCUS    OR    FILLET    AND    AQUEDUCT.  37 

lamella  on  either  side  of  the  crus  cerebri — that  from  the  nates  bein" 

O 

deeper-placed  and  overlaid  by  that  from  the  testes;  this  downward 
extension  is  called  the  fillet  of  the  quadrigeminal  bodies,  or  the 
lemniscus.  We  shall  trace  the  arms  or  brachia  and  the  lemniscus 
at  a  subsequent  stage  of  our  examination. 

Between  the  nates,  at  the  upper  end  of  their  median  raphe,  lies 
the  COnaPium  or  pineal  body  (fig.  4),  with  its  long  delicate 
brachia  extending  forwards,  and  bounding  the  white  ventricular 
surface  of  the  thalamus  above,  from  the  median  grey  walls  of  the 
third  ventricle.  Beneath  and  in  front  of  the  pineal  body  is  the 
posterior  commissure,  under  which  we  observe  the  opening  of 
the  aqueductus  sylvii  into  the  third  ventricle.  Hence  the 
quadrigeminal  bodies  lie  immediately  over  the  continuation  of  the 
central  grey  substance  of  the  ventricles  surrounding  the  aqueduct, 
which  would  be,  therefore,  laid  open  by  a  vertical  incision  carried 
through  the  median  raphe  of  the  quadrigeminal  bodies.  Moreover, 
the  descending  ribands  called  the  upper  and  lower  lemniscus  are,  in 
their  descent,  closely  approximated  to  the  outer  wall  of  the  central 
grey  substance,  which  is,  therefore,  as  it  were,  very  largely  embraced 
by  the  quadrigeminal  system. 

Just  external  to  the  central  grey  substance  are  the  various 
structures  entering  into  the  formation  of  the  tegmentum,  extending 
as  far  forwards  as  the  substantia  nigra.  If  the  peduncular  fibres 
of  the  crusta  exposed  on  one  side  of  the  pons,  upon  removal  of 
the  superficial  layers  of  the  middle  peduncle,  be  divided,  raised, 
and  the  deeper  transverse  fibres  be  dealt  with  in  like  manner, 
we  come  down  upon  the  most  anterior  layers  of  the  tegmentum, 
and  these,  when  traced,  are  found  to  be  the  fibres  of  the  lemniscus, 
which  winds  round  from  behind,  and  insinuating  itself  beneath 
the  overlapping  crusta,  passes  in  a  compact  belt  extending  even 
as  far  as  the  median  raphe  of  the  p)ons  (fig.  5,  F).  In  its  further 
course  it  is  traced  downwards  as  the  most  external  zone  of 
the  lateral  columns  of  the  spinal  cord  in  front  of  the  direct  Cere- 
bellar column.  Whilst  the  lemniscus  in  this  part  of  its  course 
gradually  ezicloses  the  several  other  tegmental  structures,  including 
the  red  nucleus,  the  fibres  given  ofi"  from  the  latter  after  decussating 
at  the  median  raphe  pass  to  the  outer  side  of  the  tegment  in  its 
further  course,  and  eventually  escape  from  the  embrace  of  the 
lemniscus  about  the  level  of  the  upper  ti'ansverse  fibres  of  the  pons, 
and,  becoming  superficial,  pass  downwards  to  the  cerebellum  as  its 
superior  peduncles.  We  must  now  follow  the  fasciculi  of  the  mesen- 
cephalon in  transverse  sections  taken  across  the  upper  and  lower 
pairs  of  quadrigeminal  bodies. 


38  THE    MESENCEPIIALOX. 

Ill  such  sections  passing  througli  the  region  of  the  nates,  five 
structures  which  demand  examination  are  exposed  to  view  ;  these 
are  in  order  from  behind  forwards — (1)  The  nates;  (2)  the  central 
grey  substance ;  (3)  the  tegmentum  ;  (4)  the  substantia  nigra ;  (5) 
the  crusta. 

(1)  The  Nates  (Superior  Bigeminal  Body). — The  ganglionic  struc- 
ture presents  four  distinct  strata — (a.)  Outer  grey  or  cortical  layer  of 
Forel.  {b.)  Longitudinal  fasciculi  from  the  external  geniculate  body, 
(c.)  Bundles  of  fasciculi  passing  outwards  on  all  sides  from  the  central 
grey  substance  in  delicate  radiations  into  the  substance  of  the  ganglion. 
(d.)  The  stratum  of  the  lemniscus,  embracing  the  grey  substance,  and 
through  which  the  radiating  fibres  last  named  have  to  pass  outwards. 
To  appreciate  correctly  the  structure  of  these  ganglia,  we  must  imagine 
a  coronal  fan  of  fibres  from  the  cerebral  cortex  converginsr  in  the 
direction  of  the  external  geniculate  bodies  into  the  substance  of  the 
cortical  layer  of  the  nates ;  passing  back  to  the  median  raphe  behind 
the  aqueduct,  and  decussating  here  with  a  similar  fasciculus  from  the 
opposite  hemisphere ;  thence  arching  around  the  central  grey  as  the 
lemniscus  already  described.  The  coronal  fasciculus  constitutes  the 
SUperiOP  brachium  of  the  nates ;  and,  2^'i"i'0r  to  the  decussation,  it 
terminates  in  the  ganglionic  cells  of  the  nates.  From  these  cells  arise 
the  fibres  which  decussate,  and  pass  as  the  lemniscus  downwards  into 
the  spinal  cord.  We  have,  therefore,  the  two  ganglia  of  the  nates, 
so  to  speak,  enclosed  between  the  upper  and  lower  arms  of  a  decus- 
sating medulla,  with  an  internode  of  ganglionic  cells  on  the  centric 
side  of  the  decussation;  and  the  lower  arms  or  stratum  lemnisci 
enclosing  in  like  manner  the  central  grey,  and  supporting  as  a  girdle 
the  mass  of  tegmentum  lying  in  front  of  the  latter.  The  upper  arm 
or  brachium  passes  in  part  direct  to  the  cortex  beneath  the  pulvinar 
of  the  thalamus,  and  thence  through  the  posterior  division  of  the 
internal  capsule ;  and  in  part,  passes  into  the  external  geniculate 
body  behind  and  covering  the  former.  This  decussating  system  of 
medulla  extends  downwards,  presenting  a  similar  formation  for  the 
testes  as  for  the  xipper  bigeminal  body  (nates).     Here  also  we  have 

an  inferior  brachium  of  the  testes,  and  an  inferior  lemniscus 

given  off  to  the  medulla  and  cord.  As  we  shall  see  later  on,  an 
almost  exact  counterpart  of  this  medullary  system  carried  forwards 
explains  the  formation  of  the  posterior  commissure  of  the  third 
ventricle. 

Both  geniculate  bodies  receive  coronal  radiations,  both  transmit 
fibres  through  the  brachia  to  the  corresponding  quadrigeminal  body, 
and  the  external  geniculate  is  intimately  connected  with  the  optic 
tract  as  the  latter  passes  to  the  nates  by  the  medium  of  the  upper 


KED    NUCLEUS    OP    TEGMENTUM.  39 

bracliium  ;  whilst  the  inferior  brachium  and  licncc  tlie  testes  have 
likewise  a  connection  with  the  inner  side  of  the  tract.  Hence  the 
nates  and  testes  arc  brought  into  relationship  with  the  cortex  of  the 
occipital  and  temporal  lobes,  as  well  as  with  the  retina.  The  radiating 
fibres  spreading  from  the  central  grey  substance  in  the  nates  through 
the  lemniscus,  are  probably  direct  connections  between  the  nerve  cells 
of  the  nates  and  the  nuclei  of  the  oculo-motor  nerves  within  the 
central  grey  area.  In  the  region  of  the  nates  also  we  observe  in 
cross-sections  numerous  fasciculi  lying  between  the  antero-lateral 
margin  of  the  grey  substance  and  the  lemniscus ;  they  pass  inwards 
between  the  red  nucleus  and  the  posterior  longitudinal  fasciculus  and 
decussate  at  the  raphe — their  destination  being  obscure.  By  Meynert 
they  are  supposed  to  be  connected  with  the  nucleus  of  the  descending 
root  of  the  fifth  nerve. 

Red  Nucleus  of  Teg"mentum  and  Upper  Cerebellar  Ped- 
uncle.— When  describing  the  structure  of  the  thalamus  we  shall  find, 
as  an  important  constituent,  a  rounded  nuclear  mass  named  the  red 
nucleus,  which,  upon  the  one  hand,  receives  coronal  radiations,  and, 
on  the  other  hand,  gives  off  medullary  fasciculi  extending  downwards 
through  the  quadrigeminal  region,  where  they  decussate  at  the  median 
raphe  to  terminate  as  the  superior  peduncles  of  the  cerebellum.  The 
nucleus  itself,  consisting  of  much  grey  matter  enclosing  large  and  small 
nerve  cells,  is  continued  into  the  region  of  the  nates,  below  which  its 
grey  matter  disappears,  and  white  medullary  fasciculi  with  interspersed 
nerve  cells  are  alone  continued  downwards  to  the  points  of  decussation. 
In  the  upper  sectional  planes  (transverse)  of  the  mesencephalon,  we 
see  this  red  nucleus  of  almost  rounded  contour  embraced  between  the 
substantia  nigra  and  commencing  lemniscus  (in  front  and  laterally) 
and  the  other  fasciculi  of  the  tegment  behind.  At  this  level  also  the 
arched  roots  of  origin  of  the  oculo-motor  nerve  lie  on  its  inner  side, 
and  partly  traverse  its  structure. 

In  the  lower  planes  of  the  mid-brain,  through  the  testes,  the 
medullary  fasciculi  derived  from  the  red  nucleus,  now  called  the 
superior  cerebellar  peduncles,  approach  the  median  raphe  and 
decussate  completely  with  the  fasciculi  of  the  opposite  side.  Through- 
out this  decussation  the  fasciculi  are  embraced  between  the  loop  of  the 
lemniscus  in  front,  and  the  posterior  longitudinal  fasciculus  behind. 
From  the  line  of  decussation  the  fasciculi  now  arch  outwards  and 
backwards,  and  still  covered  by  the  lowest  fibres  of  the  lemniscus 
derived  from  the  testes,  emerge  opposite  the  greatest  convexity  of 
the  pons  to  enter  the  cerebellum  upon  the  same  side.     If  we  adopt 

Meynert's  view  of  the  projection  system,  the  nucleus  ruber 

forms  an  internodc   or  point  of  interruption  between  the  coronal 


40  THE    MESENCEPHALON. 

fibres  of  the  cerebral  hemisphere  and  the  superior  peduncular  fibres 
of  the  opposite  cerebellar  hemisphere ;  and,  as  with  the  first  link  of 
the  projection  system  generally,  the  internode  occiirs  on  the  same 
side  as  the  hemispheres  supplying  the  coronal  attachments. 

Posterior   Long"itudinal    Fasciculus.— A  compact  column  of 

large  nerve  fibres,  oval,  somewhat  pyriform  or  lenticular,  according 
to  the  plane  of  section,  presents  itself  immediately  in  front  of  the 
central  grey  area,  and,  therefore,  behind  the  red  nucleus  or  its  decus- 
sating medulla — the  cerebellar  peduncles.  This  very  obvious 
column  of  fibres  is  seen  as  one  of  the  most  striking  features  of  the 
tegmentum  throughout  the  mesencephalon  and  down  the  whole  of  the 
medulla  oblongata.  We  have  already  seen  that  this  fasciculus 
originates  in  a  compressed  ganglionic  mass  forming  the  second  stratum 
of  the  ansa  peduncularis  (Scheme,  p.  .35),  and  that  its  coronal  origin 
is  from  the  cortex  of  the  operculum,  insula,  and  temporal  lobe;  it  is 
traced  into  the  posterior  fibres  of  the  anterior  columns  of  the  spinal 
cord. 

Substantia  Nig-ra  of  Soemmering'.— Another  formation  seen  in 
these  transverse  sections  is  the  grey  matter  of  Soemmering.  It  begins 
near  the  posterior  plane  of  the  corpora  albicantia,  and  stretches  down- 
wards to  the  lowest  limits  of  the  mesencephalon,  terminating,  there- 
fore, where  the  transverse  fibres  of  the  pons  appear.  For  the  greater 
part  of  its  course  it  stretches  completely  across  the  mesencephalon  in 
an  oblique  direction  forwards,  a  line  which,  if  continued,  would 
meet  that  of  its  fellow  at  an  acute  angle.  It  owes  its  dark  colour 
to  an  abundance  of  large  pigment  cells.  We  shall,  when  referring  to 
the  thalamus,  find  that  in  transverse  vertical  sections  through  the 
hindmost  part  of  the  third  ventricle,  this  grey  matter  lies  between 
the  crusta  and  the  red  nucleus,  and  that  a  fan  of  coronal  fibres  is  here 
seen  passing  outwards  beneath  the  thalamus  to  the  cortex  (^Meynert). 
Fibres  pass  downwards  and  forwards  from  this  grey  belt  into  the 
middle  and  inner  divisions  of  the  crusta,  and  hence  this  substance 
forms  a  ganglion  of  origin  for  certain  portions  of  the  crusta  of  the 
cerebral  peduncles,  and  although  resting  close  upon  the  tegment 
behind,  has  no  organic  connection  therewith. 

We  have  thus  traced  the  sevei-al  ganglionic  structures  and  medullary 
fasciculi,  entering  into  the  formation  of  the  mesencephalon,  and  it 
remains  but  to  summarise  the  results  of  the  inquiry.  The  mid-brain 
consists  of  two  pairs  of  ganglia,  tlu>  quadrigerainal  bodies  seated  upon 
the  brain  stem  or  pedunculus  cerebri,  where  it  diverges  as  two 
branches  or  crura,  uncovered  by  the  transverse  layers  of  the  pons,  and 
up  to  the  point  of  its  entrance  into  the  base  of  the  brain.  The  cerebral 
peduncle  consists  of  cruSta  and  tegument  severed  by  the  intervening 


RELATIONSHIPS    AXD    CONNECTIOXS    OF    TEGMENT    AND    CRUSTA.        41 

substantia  nig'ra.  The  nates  and  testes  have  intimate  connections 
through  their  hrachia  with  the  cerebral  cortex  and  retina ;  and  below, 
through  the  girdle-like  lemniscus  with  the  olivary  bodies,  and,  accord- 
ing to  Meynert,  the  lateral  columns  of  the  cord ;  both  ganglia  are 
also  connected  by  their  radiating  central  fibres  with  the  oculo-motor 
nuclei  in  the  central  grey  substance  continued  from  the  ventricle. 
In  front  of  the  ganglia  and  central  grey  substance  lies  the  structure 
of  the  tegment,  Adz.: — The  posterior  longitudinal  fasciculus;  the 
superior  cerebellar  peduncular  fibres  and  its  red  nucleus  of  origin ; 
certain  fasciculi  crossing  the  median  raphe  from  the  quadrigeminal 
bodies ;  and  lastly,  the  layer  of  the  lemniscus.  Anterior  and  external 
to  the  tegment,  is  the  crusta  with  the  substantia  nigra  lying  behind 
it.  In  the  crusta  we  recognise  the  pyramidal  tract  as  occupying  the 
inner,  middle  third,  and  the  portion  behind  and  between  these  areas, 
representing  respectively  the  accessory,  fundamental,  and  mixed 
tracts;  whilst  in  the  outer  fourth  pass  the  fasciculi  of  the  sensory 
tract.  In  high  planes  and  upon  the  innermost  fibres,  the  deepest 
layer  of  the  ansa  peduncularis  passes  backwards  to  the  nucleus  of  the 
oculo-motor.  Lastly,  the  substantia  nigra,  peculiar  to  this  region, 
represents  a  ganglion,  from  which  the  crusta  in  part  arises,  and  which 
in  itself  is  but  an  internode  for  coronal  radiations. 


THE    THALAMENCEPHALON. 

The  region  of  the  thalamencephalon  is  best  exposed  within  the  lateral 
ventricles,  for  the  study  of  its  superficial  parts  and  their  relations;  and, 
for  this  purpose,  a  dissection,  such  as  shown  in  fig.  6,  should  be  made, 
in  which  the  relative  position  of  the  mesencephalon  and  epencephalon 
are  equally  exposed.  We  here  see  the  two  great  ganglia,  the  optic 
thalami,  the  pineal  gland  with  its  peduncle,  the  central  grey  substance 
(and  the  commissure)  of  the  third  ventricle  passing  downwards 
towards  the  infundibulum,  and  the  two  corpora  geniculata  beneath 
the  hinder  extremity  of  the  thalamus  indicating  the  termination  of 
the  optic  tracts.     These,  then,  form  the  chief  structures  constituting 

the  "tween-brain  "  or  thalamencephalon.    To  appreciate  their 

mutual  relationships — their  centric  and  peripheric  connections — a 
careful  study  of  sections  carried  through  this  region  in  three  different 
planes  is  requisite — viz.,  horizontal,  longitudinal,  and  vertical-trans- 
verse ;  but  a  preliminary  study  of  their  more  obvious  external 
conformation  is  necessary  ere  a  more  minute  inquiry  is  instituted. 
The  reader  should  refer  here  to  the  illustration  (fig.  6)  given 
on  p.   29. 


42  TIIIC    TIIALAMEXCEPIIALON. 

The  optic  thalami  are  somewhat  oval,  wedge-shaped  bodies,  broadest 
behind,  where  they  diverge  from  each  other  so  as  to  expose  the 
quadrigeminal  bodies ;  and  narrowed  anteriorly  where  they  approach 
the  middle  line.  They  are  limited  externally  by  thcj  stria  tePminaliS 
(cornea),  which  is  also  the  upper  and  outer  boundary  of  the  thalaraen- 
cephalon — immediately  external  to  which  is  the  caudate  nucleus  and 
its  attenuated  tail.  In  front,  the  thalamus  presents  a  notable 
prominence,  the  anterior  tubercle ;  behind,  it  projects  back  as 
the  pulvinar,  and  forms  in  the  descending  horn  of  the  lateral 
venti'icle  the  anterior  wall  or  roof  of  the  cornu.  Mesially,  the 
thalami  are  bounded  by  the  peduncleS  of  the  pineal  body ;  and 
the  vertical  median  grey  walls  of  the  third  ventricle  do  not,  as  might 
be  conjectured,  represent  the  median  aspect  of  the  thalami,  but  must 
be  carefully  distinguished  therefrom.  In  fact,  the  mesial  aspect  of 
these  grey  masses  is  here  completely  concealed  beneath  the  grey 
matter  of  the  third  ventricle,  which  is  identical  and  continuous  with 
the  central  grey  substance  of  the  cerebro-spinal  tube  throughout  its 
length.  To  the  thalami,  however,  belong  the  middle  and  posterior 
commissures  which  cross  the  ventricle,  and  which  are  really  deCUS- 

sating"  meduUated  tracts  of  the  thalami. 

Whilst  the  inner  face  of  the  thalami  covered  by  the  central  grey 
substance  is  perpendicular,  the  outer  presents  a  kind  of  obliquely 
sloping  roof  resting  upon  the  fasciculi  of  the  internal  capsule  ;  and 
hence  the  vertical  transverse  section  of  the  thalamus  is  likewise 
somewhat  wedge-shaped  in  configui-ation.  Then,  again,  it  must  be  re- 
membered that  the  thalami  in  lower  vertebrates — birds  and  reptiles — 
are  very  evident  projections  on  the  upper  surface  of  the  peduncles  not 
included  within  the  hemisphere  at  all ;  and  that  in  man,  although 
they  appear  thus  to  project  within  the  ventricles  and  to  be  included 
within  the  more  extended  hemisphere,  they,  in  reality,  are  outside  the 
hemisphere  of  which  the  fornix  constitutes  the  median  boundary. 

We  have  spoken  of  the  thalamus  as  a  somewhat  wedge-shaped  mass, 
as  seen  in  transverse  vertical  sections.  In  similar  sections  through 
both  thalami,  they  conjointly  aj^pear  like  the  transverse-section  of  a 
boat,  keel  downwards,  in  which  the  arched  side  rests  as  on  a  couch 
in  the  concavity  of  the  internal  capsule,  whilst  in  the  hollow  of  the 
keel  the  thalamus  is  separated  from  the  capsule  by  a  region  known 
as  the  sub-thalamic  region,  in  which  a  sharply-defined,  biconvex, 
lens-shaped  body  is  situated,  to  which  we  shall  refer  later  on  as  the 
sub-thalamic  body  (lenticular  body  of  Meynert,  or  Luys'  body  of 
Forel).  The  anterior  end  of  the  thalamus,  therefore,  is  placed  at  a 
considerable  distance  from  the  base  of  the  brain  and  the  sub-thalamic 
region — the    mass    of    the    cerebral    peduncles    and    the    intervening 


THE    THALAMIC    PEDUNCLES.  43 

substantia  nigra  being  immediately  beneath  it ;  Avhilst  tlic  whole 
extent  of  the  central  cavities  of  the  third  ventricle  and  its  grey  walls 
continuous  below  with  the  infundiljulum  and  posterior  pei-foi'ated 
space,  must  be  excluded  from  the  true  thalamic  structure. 

The  interior  of  the  thalamus  consists  of  a  large  mass  of  grey  matter, 
split  into  layers  in  various  directions  by  the  medullated  strands 
passing  into  its  structure.  The  grey  matter  encloses  numerous  nerve 
cells,  which  are  the  thalamic  termini  for  coronal  radiations  connecting 
the  most  diverse  regions  of  the  cortex  with  this  body,  and  the  centres 
of  origin  for  fresh  strands  which  pass  down  into  the  tegmenhtm  of  the 
crus.  The  arrangement  of  medullated  and  grey  elements  is  peculiar. 
The  cortical  fasciculi,  as  they  enter  the  thalamus,  diverge  within  its 
structure  in  brush-like  fashion,  forming  concentric  lamellte,  between 
which  are  intercalated  the  layers  of  grey  matter  with  their  nerve  cells. 
Since  medullated  fasciculi  enter  the  thalamus  from  very  distant 
regions  of  the  cortex — from  the  frontal,  occipital,  temporo-parietal  gyri 
and  gyrus  fornicatus- — they  necessarily  meet  at  varied  angles,  and 
cross  each  other  in  their  course  within  the  ganglion  :  thus  it  is  that 
this  body  becomes  moulded  by  its  medullary  cones  into  apparently 
distinct  segments — not,  however,  true  centres  or  nuclei  in  the  usual 
acceptation  of  the  term,  since  their  grey  substance  freely  intermingles 
with  that  of  neighbouring  structures. 

The  cortical  contribution  to  the  medullated  system  of  the  thalamus 
approaches  that  body  in  part  at  its  anterior  extremity  by  three 
so-called  peduncles — the  anterior,  superior,  and  internal  (or  infei'- 
ior).  These  thalamic  peduncles  connect  its  structure  with  the  frontal 
lobe,  the  sylvian  fossa,  temporal  lobe,  and  gyrus  fornicatus  respec- 
tively. Such  cortical  fasciculi  have  necessarily  a  lengthened  course 
to  pursue,  and  none  more  so  than  that  from  the  g'yrus  forni- 
eatUS,  which  reaches  its  destination  after  a  peculiarly  complex  spiral 
course.  The  anterior  peduncle  approaches  the  thalamus  from  the 
frontal  cortex  through  the  strands  of  the  anterior  segriient  of  the 
internal  capsule  between  lenticular  and  caudate  nuclei,  interlacing 
here  with  its  fibres,  and  eventually  passing  into  the  front  end 
of  the  thalamus,  expands  brush -like  in  its  interior,  its  fibres 
arching  backwards,  crossing  the  fibres  of  the  inferior  peduncle,  and 
passing  chiefly  to  the  outside  of  the  latter.  A  portion  decussates  at 
the  middle  and  posterior  commissure,  whilst  the  rest  continues  directly 
down  the  tegmentum.  Part  of  its  fibres  help  in  the  formation  of  the 
capsule  of  the  thalamus  or  so-called  stratum  ZOnale.  The  inferior 
peduncle,  already  alluded  to  as  the  third  layer  of  the  ansa  peduneulari?, 
connected  with  the  cortex  of  the  temporal  lobe,  passes  from  beneath 
the  lenticular  nucleus  up  into  the  thalamus,  expanding  also  in  brush- 


44  THE   TIIALAMENCEPnALON. 

like  manner  chiefly  along  its  internal  portion,  and  forming  the  inner 
boundary  of  the  thalamus.  It  also  decussates  at  the  middle  and 
posterior  commissure  to  pass  down  as  teymental  fasciculi  of  the 
crus. 

Both  these  peduncular  expansions  ai'e  interrupted  by  the  nerve  cells 
in  the  grey  intercalated  layers  of  the  thalamus  ere  they  decussate  at 
the  commissures.  The  superior  peduncle  takes  a  still  mox-e  com- 
plicated course ;  its  centric  connection  is  with  the  cortex  of  the  gyrus 
fornicatus  —  appearing  first  in  the  two  fimbriae  or  posterior 
pillars  of  the  fornix  arising  from  the  cornu  Ammouis;  and  ascending 
as  the  body  of  the  fornix  connected  by  the  transverse  fibres  of  the 
lyra  upon  the  thalamus,  it  arches  forwards  at  the  front  end  of  this 
body,  and  thence  passes  downwards  as  the  two  descending"  pillars  of 
the  fornix.  These  latter  pass  back  to  the  corpora  albicantia,  around 
which  they  form  a  distinct  loop,  and  again  turn  upwards  as  the 
ascending"  pillars  or  bundles  of  Vicq  D'Azyr  to  terminate  within 
and  around  the  anterior  tubercle  of  the  thalamus.  Whilst  forming 
this  loop  around  the  COrpuS  albicans,  a  portion  of  its  fibres  is 
interrupted  by  nerve  cells  within  this  body,  and  a  fasciculus  starts 
from  this  site  and  passes  directly  backwards  into  the  tegmentum. 

Whilst  the  frontal,  insular,  and  median  cortex  is  thus  connected  by 
the  thalamic  peduncles  to  the  anterior  end  of  the  ganglia,  the  posterior 
or  hinder  half  of  the  thalamus  receives  along  its  outer  margin  coronal 
radiations  from  the  occipital  and  mid-regions  of  the  hemisphere. 
These  fasciculi  radiate  from  the  upper  and  outer  border  of  the  thalamus 
to  corresponding  regions  of  the  brain  opposite  them ;  the  middle 
section  spreading  towaixls  the  mid-regions ;  and  the  posterior  arching 
backwards  towards  the  occipital  pole.  These  latter,  as  they  pass 
outwards  and  backwards  to  the  occiput,  are  associated  wdth  similar 
radiations  proceeding  in  like  direction  from  the  geniculate  bodies  and 
the  brachia  of  the  nates  and  testes.  This  system  of  fibres  arches 
around  the  outer  wall  of  the  posterior  cornu  of  the  ventricle,  and'  has 
long  been  known  as  the  optic  radiations  of  Gratiolet.  In  their  course 
they  are  brought  into  close  association  with  the  sensoi'y  fibres  of  the 
coi'd  destined  for  the  occipital  and  temporal  lobes ;  and,  as  we  have 
previously  seen  (fig.  6,  S),  occupying  the  outer  fourth  of  the  crusta. 
This  peduncular  sensory  tract,  it  must  be  remembered,  has  no  con- 
nection with  the  optic  thalamus,  but  runs  directly  into  the  occipital 
and  temporal  regions  of  the  cortex.  The  coronal  radiations  which 
enter  this  outer  border  of  the  thalamus,  pass  through  its  structure 
as  arched  fasciculi  towards  the  median  line,  i.e.,  across  the  long  axis 
of  the  thalamus ;  the  medullated  tracts  being  intercalated  by  the  grey 
matter  common  to  the   whole    ganglion.      Upon   a  lower  level   than 


CORTICAL    CONNECTIONS    OF    OPTIC    THALAMUS.  45 

the  entrance  of  these  cortical  radiations,  other  medullated  fasciculi 
pass  into  its  substance  in  an  identical  manner  from  the  middle  root 
of  the  optic  tract,  and  this  double  origin  partially  severs  this  hinder 
region  of  the  thalamus  into  an  upper  and  a  lower  segment.  In 
both  systems  of  fibres,  hemispheric  and  retinal  (through  the  optic  tract), 
union  of  the  fibres  is  effected  with  the  cells  of  the  grey  intercalated 
layers. 

It  has  been  shown  that  the  peduncles  — anterior  and  inferior — 
entering  the  anterior  pole  of  the  thalamus,  run  backwards  through  its 
structure  as  brush-like  formations  to  terminate  in  cells  of  the  grey 
matter  ere  they  decussate  at  the  commissures ;  and  that  a  larger  pro- 
portion of  these  fresh  fasciculi  do  not  decussate,  but  pass  directly  down- 
wards into  the  tegmentum.  The  latter  direct  fasciculi,  in  passing  into 
the  hinder  half  of  the  tegmentum,  run  immediately  across  the  axis  of 
the  optic  and  COPtical  radiations  just  described;  and  necessarily 
form  apparent  concentric  dissepiments  in  these  regions.  These 
laminated  dissepiments  form  the  new  medullated  tracts  for  the 
tegmentum  arising  within  the  grey  matter  of  the  thalamus.  The 
anterior  peduncle  especially,  passing  backwards  through  the  thalamus, 
is  not  crossed  by  these  transverse  radiations,  and  its  region  is  bounded 
on  the  outer  side  by  a  strongly-marked  medullated  belt,  the  innermost 
of  the  concentric  dissepiments  alluded  to,  and  known  as  Burdach's 
lamina  medullaris.  This  well-marked  boundary  and  absence  of 
transverse  radiating  fibres,  maps  out  a  kind  of  nucleus  in  this  region 
of  the  anterior  peduncle,  which  is  known  as  the  centre  median  of 
Luys. 

On  examining  the  thalamus  from  above,  after  opening-up  the  lateral 
veiatricles,  it  is  found  that  the  grey  matter  forming  the  tail  of  the 
caudate  nucleus  may,  by  gentle  pressure  with  a  brush,  be  raised  away, 
together  with  the  stria  cornea,  from  the  subjacent  parts;  and,  imme- 
diately beneath  it,  radiating  fibres  in  coarse  fasciculi  are  seen  passing 
from  the  whole  extent  of  the  upper  margin  of  the  thalamus,  either 
directly  outwards  towards  the  parietal  lobe,  or  arching  back  towai'ds 
the  occipital  region.  These  fasciculi  consequently  form  the  outer  wall 
of  the  lateral  ventricle  in  their  course  towards  the  parietal  lobe.  If 
the  scalpel  divide  these  fibres  across  pai'allel  to  the  direction  of  the 
stria  coi-nea,  the  blade  passes  directly  into  the  internal  capsule,  and  it 
becomes  evident  that  the  outer  obliquely-placed  surface  of  the 
thalamus  rests  upon  the  internal  capsule  as  upon  a  couch,  and  gives 
ofi"  from  the  whole  of  its  outer  aspect  medullated  fibres  which  enter 
into  the  constitution  of  this  capsule,  and  then  spread  as  coronal 
radiations  to  the  various  districts  of  the  cortex  of  the  parietal  and 
temporo-sphenoidal  lobes.     The  greater  bulk  of  these  pass  deeply  into 


46  THE    TIIALAMEXCEPHALON. 

the  thalamus,  and,  as  before  said  (p.  43),  are  crossed  by  the  brush- 
like fasciculi  of  the  thalamic  peduncles.  The  more  superficial  layer 
first  I'evealed  upon  raising  the  tail  of  the  caudate,  enters  into  the  con- 
stitution of   the  white  capsular  investment   of   the  thalamus 

{stratum  zonale),  which  gives  to  this  gaugliou  its  peculiar  white  hue 
Avithin  the  ventricle,  as  contrasted  with  the  greyish  aspect  of  the 
caudate  nucleus. 

The  capsule  of  the  thalamus  spreads  inwards  as  far  as  the  peduncle 
of  the  pineal  gland  ere  it  turns  downwards  to  form  part  of  the 
inner  investment  of  the  thalamus ;  and  at  this  line  it  disappears 
from  view,  and  tlie  grey  matter  of  the  third  ventricle  becomes 
apparent.  This  cajDsule  or  stratum  zonale  is  itself  of  complex 
formation  :  it  receives  also  fibres  from  the  optic  tracts,  the  upper- 
most of  those  which  join  the  thalamus;  so  also  fasciculi  from  the 
frontal  lobe  enter  it  by  the  anterior  peduncle  of  the  thalamus,  and  in 
like  manner  the  most  superficial  stratum  of  the  ansa  lenticularis ; 
lastly,  the  gyrus  fornicatus  sends  its  contribution  hy  means  of  the 
ascending  pillar  of  the  fornix,  which  in  this  course  embraces  a  nodular 
segmented  portion  of  the  thalamus  at  its  anterior  extremity,  termed 
the  anterior  tubercle.  Hence  the  zonular  layer  or  thalamic  capsule 
receives  fibres  from  almost  every  region  of  the  brain — the  frontal, 
parietal,  temporo-sphenoidal,  and  occipital  lobes,  and  the  mesial  aspect 
or  gyrus  fornicatus,  as  well  as  the  retina.  This  very  extensive  retinal 
and  hemispheric  connection  of  the  thalamus  may  be  thus  tabulated : — 

Fasciculi  from 

Frontal  lobe,      .  .  .      Through  anterior  peduncle  of  thalamus. 

Temporo-sphenoidal  lobe,        ,       Coronal  radiations  and  superficial  layer  of 

ansa  lenticularis. 
Parietal  and  occipital  lobes,    .       Coronal  radiations  along  its  whole  outer 

surface. 
Gyrus  fornicatus,  .  .      Through  pillars  of  fornix. 

Retuia,     ....       Through  uppermost  thalamic  connections 

of  optic  tract. 

The  Pineal  Body  and  its  Connections. — Surmounting  the  upper 

pair  of  the  quadrigeminal  bodies,  immediately  beneath  the  posterior 
exti'emity  of  the  callosal  commissure  and  in  the  middle  line  between 
the  mesencephalon  and  diencephalon,  lies  a  small,  reddish,  somewhat 
conical  structure — the  pineal  body.  It  is  closely  attached  to  the 
velum  interpositum,  so  that  it  is  frequently  torn  away  with  the 
membranes  investing  it.  It  is  hollowed  into  several  small  sacculi, 
which  contain  the  gritty,  earthy,  and  amylaceous  material  termed 
acervulus  cerebri  :  and  the  structure  is  peculiarly  vascular.  In 
microscopic  structure  we  find  it  consists,  like  other  ganglionic  struc- 


THE    PINEAL    BODY    AND    FASCICULUS    RETROFLEXUS.  47 

tares  in  the  brain,  of  closely  aggregated  cells,  varying  considerably  in 
size  from  5  /x.  to  18  n,. 

Its  connection  with  the  rest  of  the  cerebrum  is  effected  by  means 
of  two  processes,  which  are  directed  forwards  along  the  inner  bordei' 
of  the  thalami  optici,  forming  a  boundary  between  the  latter  and  the 
grey  matter  of  the  third  ventricle;  and  descending  in  front  in  conjunc- 
tion with  the  taenia  semicircularis  and  the  pillar  of  the  fornix  :  these 
are  the  two  peduncles  of  tlie  pineal  body  or  habenula.  Tliese 
peduncles  are  distinctly  ganglionic  in  structure,  and  together  Avith  the 
pineal  body  are  probably  to  be  regarded,  as  Meynert  believes,  as  ganglia 
of  origin  for  the  tegmentum. 

The  connections  by  medullated  tracts  are  twofold — centric  and 
peripheric.  The  former,  as  a  connection  with  the  cerebral  hemi- 
spheres, takes  place  through  the  medium  of  the  stratum  zonale,  already 
described  as  investing  the  optic  thalamus. 

The  latter  or  peripheric  connection  is  effected  by  a  large  and 
important  fasciculus,  which  passes  down  vertically  from  the  habenula 
or  peduncle,  covered  by  the  grey  matter  of  the  third  ventricle,  and 
towards  the  region  (at  the  base)  of  emergence  of  the  motor  oculi  nerve 
on  the  inner  side  of  the  converging  crura.  In  this  course  it  describes 
a  sigmoid  bend,  and  near  the  base  of  the  mesencephalon  it  lies  between 
the  posterior  longitudinal  fasciculus,  on  the  median  aspect,  and  the 
red  nucleus  of  the  tegmentum,  external  to  it.  Some  of  its  fibres  radiate 
into  the  nucleus  ruber  (Meynert) ;  but  the  larger  proportion  bend  at 
this  point  immediately  backwards  at  right  angles  to  their  former  course, 
and  appear  to  pass  into  the  tegmental  areas  of  the  pons  and  medulla, 
in  conjunction  with  the  posterior  longitudinal  fascicuhis.  This  rectan- 
gular bend  has  gained  for  it  the  appellation  of  the  faSCiCUlus  retro- 
flexUS — it  is  often  termed  the  style  of  the  peduncle  of  the  pineal 
body,  where  it  passes  vertically  towards  the  red  nucleus  of  the 
tegmentum. 

The  style  or  fasciculus  retrojlexus  may  be  best  exposed  by  trans- 
verse vertical  sections  carried  through  the  ganglion  of  the  peduncle 
just  in  front  of  the  quadrigeminal  bodies,  but  it  may  also  be  traced 
in  longitudinal  vertical  sections  near  the  mesial  plane  of  the  "  tiveen 
and  mid  brain."  In  these  sectional  planes,  however,  owing  to  its 
sigmoid  flexure,  a  part  only  of  its  course  can  be  usually  seen.  Thus 
in  a  vertical  longitudinal  section  of  the  brain  of  the  dog,  near  the  mesial 
plane,  we  find  the  lower  end  of  this  fasciculus  about  to  bend  backwards 
at  right  angles,  and  on  this  plane  it  is  seen  to  descend  in  front  of 
medullated  fasciculi  passing  downwards  from  the  posterior  commissure 
and  the  emergent  i"oots  of  the  third  nerve.  In  a  section  carried  still 
nearer  the  mesial  plane,  we  see  its  course  about  complete,  whilst  a 


48  THE    TIIALAMENCEPIIALON. 

portion  of  both  ascending  und  descending  pillars  of  the  fornix  is  revealed 
likewise. 

Posterior  Commissure. — Wo  have  already  traced  the  anterior 
and  inferiur  peduncles  of  the  tlialnmus  as  far  as  their  decussation 
in  the  posterior  comniissiire,  and  it  would  seem  extremely  probable 
that  the  fasciculus  retrojlexus  undergoes  partial  decussation  through 
the  medium  of  this  commissure  also.  Near  the  mesial  line,  we  can 
readily  ti'ace  these  decussating  fibres  of  the  posterior  commissure  in 
their  further  course  passing  downwards  into  the  tegmentum,  where 
they  bend  backwards  to  pass  into  the  medulla  and  spinal  cord ; 
whilst  prolonged  from  the  posterior  commissure  backwards  is  also 
seen  the  cross-section  of  the  meduUated  fibres  of  the  corpora 
quadrigemina. 

In  these  vertical  longitudinal  sections  taken  near  the  mesial  plane, 
we  therefore  see  three  systems  of  decussating  fasciculi  crossing  at 
the  middle  line,  and  forming  periphei'ic  extensions  from  a  series 
of  ganglionic  bodies,  viz.  : — The  fasciculus  retroflexUS,  the  mass 
of    the    posterior    commissure,    :^nd    the    quadrigcminal    fasciculi 

called  the  lemnisci  or  fillets  of  the  nates  and  testes. 

Corpora  Geniculata. — Beneath  the  pulviuar  of  the  thalamus 
in  man  we  see  a  small  club-shaped  body  about  the  size  of  a  coffee- 
bean,  directly  continuous  with  the  optic  tract  anteriorly,  and  by  a 
notable  border  separating  mesencephalon  from  tltalamenceplialon,  con- 
nected Avith  the  upper  quadrigeminal  body  or  nates.  This  small 
ganglion,  for  ganglionic  it  is  in  nature,  is  the  outer  g'eniculate 
body,  and  lies  in  the  course  of  the  arm  of  the  nates  or  superior 
hrachium,  with  which  it  is  intimately  connected,  as  it  proceeds  to  the 
cortex  of  the  occipital  lobe.  Upon  vertical  longitudinal  section  it  is 
found  to  possess  a  peculiar  plicated  arrangement  of  a  medullated  and 
a  grey  lamina,  exhibiting  alternating  layers  of  grey  and  white 
substance. 

Internal  to  this  body,  that  is,  nearer  the  mesial  plane,  lies  another 
small  structure  of  spindle-shaped  outline,  immediately  beneath  the 
upper  and  between  it  and  the  lower  brachium ;  it  is  directed  towards 
the  nates  by  one  of  its  pointed  extremities.  This  structure  is  the 
inner  g'eniculate  body.  Both  geniculate  bodies  are  connected  with 
the  corpora  quadrigemina  on  the  one  hand,  and  with  the  cortex  of 
the  occipital  lobe  along  with  the  other  centric  fasciculi  of  the 
brachia.  In  a  vertical  section  we  find  an  extensive  portion  of 
the  optic  tract  directly  continuous  with  this  plicated  outer  geniculate 
sanglion,  and  hence  also  with  the  nates.  An  inner  segment 
of  the  oi:)tic  tract,  but  much  more  limited  in  extent,  passes  into 
the   internal    geniculate    and    thence    to    the    nates   also ;    no   fibres 


CONFIGUnATION    OF    CEREBUAL    IIEMISPIIERK.S.  4^ 

from    tlie   optic    nerve    are   believed    to    pass    by    this    tract    to    the 
testes. 

The  remaining  connections  of  the  optic  tract  arc  the  optic  thalamus 
(to  the  stratuvi  zonule  and  radiating  fasciculi  previously  described) ; 
and  the  basal  optic  ganglion,  a  small  body  of  grey  matter  lying  beside 
the  tuber  cinereiim  immediately  covered  by  the  optic  commissure. 
The  ganglia  of  origin  of  the  optic  nerves,  therefore,  are  the  upper 
quadrigeminal,  the  outer  and  inner  geniculate  bodies,  the  optic 
thalamus,  and  the  basal  optic  ganglion  :  the  centric  or  coronal 
extensions  arising  in  these  ganglia  pass  by  means  of  the  posterior 
section  of  the  internal  capsule  as  the  optic  radiations  of  Gratiolet  to 
the  cortex  of  the  occipital  and  ( % )  tempoi-o-sphenoidal  lobes. 


PROSENCEPHALON   OR  FORE-BRAIN. 

Config'Uration. — We  have  already  seen  that  divei'gence  of  the 
brain-stem  in  the  crura  cerebri  to  reach  either  hemisphere,  entails 
also  the  more  and  more  complete  severance  of  the  various  ganglionic 
masses  at  the  base  with  which  it  is  brought  into  connection  :  and 
that  from  the  bilateral  fusion  of  the  mesencephalon,  we  pass  forward 
to  the  divergent  masses  of  the  thalami  (diencephalon),  and  thence  to 
the  still  further  severed  corpora  striata,  constituting  the  ganglia  of  the 
fore-brain  (prosencephalon).  We  have  seen  how  these  more  divergent 
masses  are  braced  together  by  sling-like  loops  of  medulla,  such  as 
the  ansa  lenticularis,  and  united  mesially  by  the  anterior  and  other 
commissural  ti^acts.  The  ganglia  of  the  prosencephalon  form  the  most 
anterior  mass  of  grey  matter  surrounding  the  peduncular  extensions, 
and  are  so  disposed  as  to  constitute  two  incompletely-severed  masses  ot' 
grey  substance,  whose  configui-ation  shadows  forth  the  form  assumed  by 
the  hemispheric  envelope  moulded  around  them.  The  flexure  of  the 
fore-brain,  whereby  this  hemispheric  arc  reproduces  the  contour  of 
these  ganglionic  structures,  has  its  site  at  the  fissure  of  Sylvius  ;  and 
in  foetal  brains,  ere  the  further  differentiation  of  the  cortex  into  its 
varied  longitudinal  and  transverse  fissures  has  proceeded,  we  see 
readily  how  the  hemispheres  are,  so  to  speak,  moulded  after  the  form 
of  their  subjacent  ganglia.  The  axis  of  this  flexure  is  constituted  by 
the  most  external  of  these  ganglionic  masses,  the  so-called  lenticulaP 
nucleus,  wedge-shaped  in  form,  its  base  directed  forwards  and  out- 
wards, covered  by  the  cortex  of  the  insula — its  apex  downwards  and 
inwards  towards  the  cms  cerebri.  Around  this  wedge-shaped  axis,  the 
ganglionic  and  hemispheric  arcs  are  severally  formed — the  ganglionic  in 
the  form  of  the  caudate  nucleus  :  the  hemispheric  beginning  at  the 


50 


THE    PROSENCEPHALON. 


orbital  aspect  of  the  frontal,  sweeps  round  the  fronto-parietal  to  the  tip 
of  the  teniporo-sphenoidal  lobe.  The  more  flattened  aspect  of  the 
retjion  of  tlie  insula,  therefore,  bears  the  impress  of  the  base  of  this 
lenticular  axis  of  revolution,  whilst  the  more  spheroidal  contour  of 
the  hemisphere  conforms  to  the  curvature  of  the  caudate  body. 

Upon   this   constructive   principle   largely  depends   the   divergence 
observed  in  the  primitive  contour  of  the  cerebrum  in  various  animals 


JV.c 


Fig.  7.— Section  through  hemispheres  (vertical  transverse)  through 
plane  of  middle  commissure. 


I^.c,  Tail  of  caudate  nucleus. 

C.c,  Corpus  callosum. 

F,  Fornix  and  choroid  plexus. 

a,  Internal  capsule. 

T.o,  Optic  Tlialamus. 


Cm,  Middle  Commissure. 
C.e,  External  capsule. 
CI,  Claustrum. 

1,  2,  3,  Three  segments  of  lenticular 
nucleus. 


and  in  man.  Although  identical  in  the  nature  of  their  histological 
constituents,  these  two  ganglionic  masses  differ  widely,  not  alone  in 
their  rough  contour,  but  in  their  quantitative  relationships  :  in  certain 
brains,  the  caudate  nucleus  assumes  a  mass  far  out  of  all  proportion  to 
the  lenticular ;  whilst  in  man,  the  former  is  dwarfed,  and  the  latter 
assumes  a  relatively  important  role.  The  greater  magnitude  assumed 
by  this  lenticular  axis  of  revolution,  the  greater  the  scope  for  the 
unfolding  of  the  hemispheric  arc,  and  the  more  important  the  develop- 
mental features  assumed  by  the  regions  of  the  insula  and  sylvian 


LKNTICULAR    AND    CAUDATE    NUCLEI.  51 

fussa.  On  the  other  hand,  the  smaller  lenticular  body,  and  the  larger 
proportionate  development  of  the  caudate  bespeak  a  brain  of  simple 
configuration,  more  spherical,  less  complex  in  convolutionary  arrange- 
ment, and  of  more  uniform  symmetry  throughout. 

In  thus  indicating  their  impress  in  the  configuration  of  the  cerebral 
vault,  these  striate  ganglia  differ  widely  from  the  diencephalic 
gang-lia  previously  considered,  the  thalami  Optici  ;  in  fact,  these 
latter  bodies,  so  far  from  having  any  portion  of  the  cerebral  hemi- 
sphere moulded  to  their  form,  are  themselves  wholly  outside  the 
cerebi-al  envelope  in  their  mesial  position.  Thus,  the  adult  brain 
witnesses  to  the  genetic  relationship  of  the  cerebral  hemispheres,  and 
the  related  striate  ganglia  :  the  whole  mass  in  front  constituting  the 

fore-brain  or  prosencephalon  in  advance  of  the  thalamence- 
phalon. 

We  have  spoken  of  these  basal  ganglia  as  incompletely  severed 
masses  of  grey  matter,  a  statement  at  once  verified  by  vertical 
sections  taken  in  anterior  planes  through  these  bodies.  In  such 
antei'ior  planes,  the  medullated  interval  elsewhere  separating  these 
bodies  is  bridged  by  numerous  broad  bands  of  grey  substance  which 
are  but  extensions  from  one  to  the  other  ganglion ;  whilst,  at  the  base, 
complete  fusion  occurs  between  the  two,  the  head  of  the  caudate 
nucleus  merging  into  the  frontal  extension  of  the  lenticular,  becom- 
ing so  superficial  at  the  base  as  to  be  merely  covered  over  by  the 
orbital  medulla  and  the  grey  matter  of  the  anterior  perforated  space 
with  which  it  becomes  continuous. 

Caudate  Nucleus. — The  innermost  or  intraventricular  nucleus  of 
the  ganglion  of  the  fore-brain,  and  the  only  portion  superficially  seen 
within  the  lateral  ventricles,  is  of  pyriform  shape,  with  a  long 
attenuated  tail-like  process  extending  into  the  temporal  lobe.  In 
this  coui-se,  as  before  explained,  it  is  bent  upon  itself,  its  axis  of 
revolution  being  the  lenticular  body.  The  head  of  the  ganglion 
fusing  at  the  base  with  the  lenticular,  arches  forwards  and  inwards 
towards  the  septum  lucidum,  and  lying  on  the  inner  aspect  of  the 
internal  capsule,  embraces,  in  this  first  part  of  its  course,  an  important 
medullated  fasciculus,  which  connects  the  coi'tex  of  the  frontal  lobe 
with  the  antei'ior  extremity  of  the  optic  thalamus,  the  so-called 
anterior  thalamic  peduncle.  In  its  further  course,  it  ascends 
above  the  level  of  the  lenticular,  and  lies  upon  the  internal  capsule ; 
its  tail-like  extension  resting,  opposite  the  thalamus,  upon  the  hemi- 
spheric fibres  which  pass  beneath  it,  to  form  the  capsular  investment 
of  the  thalamus  [stratum  zonule).  Still  further  back,  the  tail  arches 
downwards  into  the  descending  liorn  of  the  ventricle,  and  can  be 
traced   upon  the  roof  of  the   latter  as  far  forwards   as  its  anterior 


52  THE    PROSENCEPHALON. 

extremity,  wliere  it  terminates  in  a  somewhat  bulbous  end,  liaving 
immediately  in  front  of  it  a  mass  of  grey  matter,  termed  tlie 
amyg'dala.  It  will  be  seen  from  this  descri])tion  that  the  bulbous 
extremity  of  the  tail  extends  almost  as  far  forwards  as  the  head  of  tlie 
caudate  nucleus,  and  thus  describes  an  almost  complete  loop  around 
the  internal  capsule  and  thalamus,  hence  termed  the  *'  SUrcingle." 
The  -whole  course  of  tliis  loop  can  be  well  demonstrated  l)y  veitical 
longitudinal  sections  of  the  hemisphere ;  whilst  vertical  transverse 
sections  anywhere  between  the  amygdala  and  posterior  end  of  thalamus 
reveal  the  ui)))er  and  losver  segments  of  the  surcingle,  as  isolated  grey 
masses  above  and  below  the  thalamus.  Each  of  these  prosencephalic 
ganglia  has  a  surface  perfectly  free,  that  is,  devoid  of  meduUated 
attachments — and  other  aspects,  -svhich  present  the  termini  of  centric 
and  peripheric  sti'ands.  Thus,  the  ventricular  aspect  of  the  caudate 
together  with  the  base  of  the  lenticular  wedge  (insular  aspect) 
are  alike,  smooth  and  devoid  of  medullated  connections  :  whilst  the 
opposed  surfaces,  separated  by  the  intervening  capsular  fibres,  as  well 
as  the  basal  or  inferior  aspect  of  the  lenticular  nucleus,  are  the 
surfaces  for  the  termination  and  departure  of  the  numerous  medul- 
lated connections  of  this  with  distant  regions.  Since  the  lenticular 
body  lies  beneath  the  internal  capsule,  its  temporal  extremity  is 
sepai-ated  for  some  distance  by  that  formation  from  the  temporal 
extremity  or  cauda  of  the  intx'aventricular  nucleus.  Posteriorly, 
however,  they  approach  each  other,  and  bridges  of  grey  niatter  connect 
them,  separated  by  medulla.  They  are  also  separated  here  by  the 
centric  extension  (brachiura)  from  the  external  geniculate  body ;  and 
finally  along  the  roof  of  the  descending  cornn  these  two  temporal 
extremities  fuse  together,  forming  the  lower  segment  of  the  snrciiKjle. 

The  constitution  of  the  surcingle,  therefore,  is  diflerent  in  its  upper 
and  lower  arc,  being  purely  an  extension  of  the  innermost  nucleus 
above ;  but  formed  out  of  the  fused  tempoi-al  extremities  of  both 
prosencephalic  nuclei  below.  It  cannot  fail  to  impress  the  student 
that  the  ganglionic  structures  and  their  extensions,  so  far  described, 
encircle  in  a  series  of  loop-like  formations  the  medullated  core  which 
passes  from  the  spinal  cord  and  medulla  upwards  as  peduncles  and 
capsule  to  the  cerebral  hemispheres. 

First,  thei-e  is  the  mesencephalon,  the  quadrigeminal  bodies,  each 
throwing  downwards  its  loop-like  Jillet  or  leimdscns ;  and  throwing 
upwards  its  centric  arm  in  the  form  of  the  hrachia.  At  a  liigher  level, 
the  thalamencephalon  shows  us  the  optic  thalamus  astride  the  posterior 
edwe  of  the  internal  capsule  arching  backwards  around  it  to  form  the 
roof  of  the  descending  horn  of  the  lateral  ventricle;  whilst  its  centric 
extensions  pass  upwards  to  the  cortex  from  its  outer  surface  beneath  the 


STRIA    TERMINALIS — OLFACTORY    AREA.  53 

tail  of  the  caudate.  Then  still  higher  M'e  get  the  arcof  the  caudate  body 
asti-ide  the  anterior  edge  of  the  internal  capsule  with  its  long  tail-like 
loop  also  passing  down  the  roof  of  the  descending  cornu'^in'conj unction 
with  that  of  the  lenticular :  whilst  still  further  outwards  is  the  mass 
of  the  internal  capsule  becoming  free  as  coronal  radiations  to  the 
various  parts  of  the  hemisjihere.  For  descriptive  purposes  it  is 
convenient    to     distinguish     between    uppGP    or    ventPiCUlar,    and 

lower,  cornual  or  temporal  arc  of  tlie  surcinfjle:  tlie  caudal 

extremity',  the  body  of  the  caudate  nucleus,  and  its  caput  directed 
towards  tlie  base  :  whilst  we  also  s):)eab  of  its  ventricular  and 
capsular  aspects. 

In  like  manner  the  lenticular  nucleus  has  its  frontal,  its  temporal, 
and  peduncular  or  crustal  extremity;  its  insular  aspect  (or  base  of 
wedge),  its  inferior  aspect,  its  capsular  aspect.  So  also  the  capsular 
constituents  may  also  bear  the  convenient  terminology — COrtlCO- 
Striate   and   COrtiCO-lentiCUlar  fasciculi  for    the]  centric   bundles  : 

pedunculo-striate  and  pedunculo-lenticular  for  the  peripheric 

bundles  :  direct  peduncular  for  those  uninterrupted  by  the  prosen- 
cephalic  ganglia. 

Stria  TerminaliS. — A  glistening  white  band  of  fibres,  strongly 
contrasting  with  the  adjacent  grey  cauda,  varying  from  one  to  two 
millimetres  in  diameter,  lies  along  the  inner  border  of  the  tail  of  the 
caudate  body  throughout  its  whole  length,  extending ^from  the  tip  of 
the  temporo-sphenoidal  lobe  along  the  roof  of  the  descending  cornu, 
and  along  the  upper  arc  of  the  surcingle  betwixt  it  and  the 
thalamus,  as  far  as  the  anterior  end  of  the  latter.  Inferiorly  it  is 
distributed  to  the  amygdaloid  nucleus  ;  and  by  Meynert  is  regarded 
as  ai'ising  from  the  head  of  the  caudate  nucleus.  Schwalbe,  on  the 
other  hand,  regards  this  conclusion  as  dubious,  and  expresses  the 
ojoinion  that  it  possibly  has  no  connection  whatever  ^with  the  ganglion. 
By  other  authorities — Meckel,  Arnold,  Jung,  and  Luys — this  arciform 
"band  has  been  presumed  to  terminate  in  the  descending  pillar  of  the 
fornix.  This  lengthened  arciform  structure,  which  has  been  also 
called  the  tsenia  semicircularis,  would  appear  from  its  greater 
proportionate  development  to  be  an  important  structure  in  the  brain 
of  rodents  ;  in  the  dog,  on  the  other  hand,  it  is  comparatively  insigni- 
ficant in  size.  In  the  rabbit  it  can  be  clearly  seen  to  consist  of  a 
superficial  and  deeper  fiisciculus  at  its  termination,  and  to  be  con- 
nected throughout  its  course  with  the  caudate  nucleus  :  the  latter 
arches  downwards  behind  the  anterior  commissure  just  to  the  inside 
of  the  lower  margin  of  the  internal  capsule,  as  seen  in  vertical  sections: 
these  fibres  appear  to  terminate  in  the  area  at  the  base  known  as 
Gratiolet's  olfactory  area— embraced,  in  fact,  within  the  trigonum 


54  Tin;  imjosknckimialon. 

olfactOPium.  It  would  be  liazardous  to  affirm  that  none  of  the 
siipL'iticial  fibres  enter  the  descending  pillar  of  the  fornix,  as  stated  by 
several  authorities ;  but  in  the  rodent  it  appears  easily  demonstrable 
that  this  fasciculus,  in  great  part  at  least,  enters  the  anterior  com- 
missure from  beliind  in  such  a  direction  as  to  ensure  decussation,  and  so 
bring  the  hippocampal  region  and  caudate  nucleus  into  crossed  relation- 
ship with  the  olfactory  bulb.*  We  shall  refer  to  this  connection 
further  on  when  dealing  with  the  relationships  of  the  anterior  com- 
missure. 

Lenticular  Nucleus. — Although  in  section  both  vertical  and  hori- 
zontal, this  ganglion  exhibits  a  distinctly  wedge-shaped  contour,  its 
name  of  lenticular  is  justified  upon  inspection  of  its  outer  or  insular 
aspect.  This  can  only  be  done  by  freeing  it  of  its  medullated  connec- 
tions— an  opei'ation  readily  efi'ected  either  by  dissection  or  the  brush, 
the  ganglia  being  held  beneath  w-ater,  whilst  the  medullated  invest- 
ments are  dissected  off  or  brushed  away.  In  this  manner  it  is  easy 
to  isolate  the  two  ganglia  of  the  prosencephalon  attached  to  each  other, 
for  the  pux-pose  of  recognising  their  fundamental  configuration. 

The  lenticular  then  appeal's  to  be  a  distinctly  lens-shaped  body, 
especially  if  looked  at  from  above,  where  a  section  of  the  internal 
capsule  at  the  foot  of  the  COrona  radlata  separates  it  from  the 
caudate  nucleus  within.  It  will  then  also  be  apparent  that  the 
caudate  applied  at  first  to  the  inner  side  of  the  internal  capsule  and 
lenticular  mounts  higher  and  higher  so  as  to  lie  with  its  attenuated 
tail  U2)0n  the  former  and  above  the  latter.  The  smooth  lens-shaped 
exterior  of  this  structure  is  overlaid  by  a  medullated  investment — the 
external  capsule,  loosely  applied  to  it,  occasionally  the  site  of  haemor- 
rhage, which,  breaking  into  the  intervening  tract,  separates  it  from  the 
surface  of  the  lenticular. 

External  to  this  capsule  comes  the  claustrum,  and  lastly  the 
medulla  and  cortex  of  the  insula  or  island  of  Reil.  Upon  section 
this  ganglionic  body  shows  a  well-defined  triple  segmentation — dis- 
tinguished by  the  grey  aspect  of  the  outer,  and  the  increasing  pallor 
and  tawny  pigmented  aspect  of  the  more  internal  segments;  the  inner- 
most and  largest  which  is  notably  pale  and  pigmented  being  designated 
the  globus  pallidus  (fig.  7).  These  three  divisions  are  not  merely 
distinguished  by  their  diflerence  in  colour,  but  are  separated  by  well- 
marked  dissepiments  called  laminae  medullares,  which,  as  thin 
medullated  partitions  descend  from  the  internal  capsule  down  to 
the   basal    aspect    of  the    brain,   lying   concentrically   to    the    insular 

*See  "Comparative  Structure  of  the  Brain  iu  Kodents,"  by  the  Author,  in 
the  Philosophical  Transactions,  part  ii.,  1882,  page  730. 


TUE  BRAIN  IX  LOWER  VERTEBRATA.  55 

aspect  of  the  gangliou  :  two  and  sometimes  three  such  dissepiments 
exist.  The  medullated  fibres  forming  these  dissepiments,  and  arising 
from  the  internal  capsule,  bend  inwards  at  diSerent  points  to  form 
radial  fibres  all  directed  towards  tlie  peduncular  end  of  the  wedge; 
a  certain  proportion,  however,  comjjletely  traverse  the  lenticular  as 
laminae  meduUares ;  and  escaping  at  the  base  of  the  ganglion  pui'sue 
their  course  towards  the  crusta,  as  a  sort  of  capsular  sling,  covering 
the  base  of  the  lenticular  and  forming  one  layer  of  the  so-called  arisa 
lenticularis  already  refen-ed  to.  Since  each  segment  is  traversed  not 
only  by  fibres  originating  in  the  cells  of  its  territory,  but  also 
receives  those  passing  into  it  from  an  outer  segment  and  its  medullary 
laminse,  it  follows  that  the  narrow  or  peduncular  end  of  the  wedge 
becomes  constituted  by  a  closely  packed  system  of  medullated  fibres 
where  they  enter  the  crus  cerebri ;  and  it  is  this  preponderance  of 
fibre  over  grey  matter  which  gives  to  the  inner  segment  (globus 
pallidus)  its  characteristic  pallor. 


THE   ENCEPHALON   AS   A   WHOLE. 

Comparative  and  Embryolog'ical.— The  earliest  indication  of  a 
brain  in  the  vertebrate  series  consists  in  a  slight  bulb-like  dilatation 
at  the  end  of  the  neural  tube.  This  is  all  that  ever  occurs  in  the 
low^est  form  of  vertebrate  animals— the  amphioxUS  or  lancelet, 
which  therefoi'e  presents  as  a  permanent  structure  the  earliest,  but 
transitory,  phase  of  development,  through  which  all  higher  vertebrata 
pass,  even  to  man  himself.  A  step  higher,  the  lamppey  exhibits  a 
large  pyriform  dilatation  of  the  neural  tube,  and  retains  for  a  long 
period  this  rudimentaiy  form,  which,  however,  in  comparison  with 
its  spinal  system,  bears  to  it  scarcely  a  higher  pi'oportionate  size  than 
do  the  cephalic  ganglia  of  insects  to  their  ventral  ganglia. 

Still  higher  in  the  vertebrate  series,  in  flshes  and  amphibia,  we 
find  that  this  bulb-like  distention  of  the  neui-al  axis  becomes  very  early 
transformed  by  ti'ansverse  constrictions  of  the  former  elongated  bulb, 
into  a  series  of  five  pairs  of  vesicles,  which  lie  in  linear  series,  one 
behind  the  other,  and  which  are  reproduced  in  every  form  of  verte- 
brate, higher  in  the  series,  at  a  certain  stage  of  its  developmental 
history.     These  five  vesicles  represent  what  in  higher  animals  become 

respectively  the  fore-brain  or  cerebrum,  the  twixt-brain,  the 
mid-brain,  the  hind-brain,  and  the  after-brain. 

These  several  parts  in  fishes  and  ampliibia  represent  elements  of  the 
higher  vertebrate  brain,  which  remain  ])ermaneut  in  them,  but  subject 
to  most  diverse  modifications  in  structural  complexitv  and  in  relative 


56  THE    ENCEPIIALON — COMPARATIVE. 

preponderance  of  one  or  other  segment.  The  lully  developed  brain  in 
fishes  presents  great  variety  in  the  relative  size  of  the  individual  lobes. 
Tn  the  first  place,  the  early  ditl'erentiation  between  the  vesicle  of  the 
twixt-brain  and  mid-brain  becomes  obscured  in  most  fishes,  so  that  the 
fully  formed  organ  shows  us  but  four  gangliated  swellings,  lying  one 
behind  the  other  in  scries,  and  representing  (1)  the  Cerebral  hemi- 
spheres; (2)  the  optic  lobes;  (3)  the  cerebellum;  {i)  the  medulla. 

The  two  former,  as  seen  in  the  brain  of  the  perch,  are  disposed 
in  pairs,  whilst  in  front  of  the  cerebral  hemisi)hei-es  we  see  yet 
two  small  bulbous  swellings,  from  which  arise  the  olfoctory  nei'ves, 
and  which  are  called,  therefore,  the  olfactory  g'ang'lia.  These 
ganglia  are  absent  in  the  Shark,  Skate,  Whiting,  Szc,  and  are  replaced 
by  an  elongated  peduncle  capped  at  the  extremity  by  the  ganglia  as  in 
man. 

The  cerebral  hemispheres  in  fishes  are  usually  smaller  than  the 
optic  lobes,  e.g.,  in  the  Whiting,  Carp,  Pike,  Perch  ;  but  in  the  Shark, 
the  Skate,  the  Lepidosiren,  and  others,  they  very  greatly  exceed  these 
lobes  in  their  dimensions.  Behind  the  cerebral  hemispheres  appear 
the  optic  lobes,  which  in  the  fish,  it  must  be  remembered,  represent 
the  thalamencephalon  (thalamus  and  third  ventricle)  as  well  as  the 
mesencephalon  (or  in  man  what  corresponds  to  the  corpora  quadri- 
gemina).  Thus,  if  we  turn  to  the  brain  of  the  perch,  we  see  in  front 
the  two  small  olfactory  lobes,  followed  by  a  lai'ge  pair  of  cerebral 
hemispheres,  and  these  in  their  turn  by  the  still  larger  pair  of  optic 
ganglia,  with  a  small  tubercle  projecting  in  front  between  them  and  the 
cerebrum.  This  latter  body  is  the  pineal  g'land,  indicating  the 
neighbourhood  of  the  thalamencephalon,  with  which  it  is  connected. 
At  the  base  the  same  structures  are  seen  in  front;  but  the  optic  lobes 
present  two  peculiar  lobulated  bodies  called  hypoaria  or  the  lobl 
inferiores,  whose  significance  is  unknown:  they  are  peculiar  to  fishes. 
From  the  centre  pi-ojects  the  pituitary  body,  whilst  the  optic  nerves 
are  seen  to  originate  from  the  base  of  this  ganglion,  and  cross  (without 
decussation  of  fibres)  to  the  opposite  sides. 

In  insects  these  optic  lobes  repx'esent  the  chief  part  of  their 
cephalic  ganglia.  Behind  the  optic  lobes  comes  a  single  tongue-like 
lobe — the  cerebellum — the  size  of  which  apparently  bears  a  direct 
relation  to  the  power  and  muscular  activity  of  the  fish.  Thus  the 
rapacious  shark  has  an  enormous  cerebellum,  w^hilst  in  the  more 
sluggish  fish,  it  is  relatively  small;  in  osseous  fishes  it  is  usually  con- 
siderably below  the  size  of  the  optic  lobes.  The  last  division  of  the 
brain  is  the  medulla,  lying  immediately  behind  and  beneath  the 
cerebellum,  ni;i])ped  oil  from  the  spinal  cord  by  its  somewhat  larger 
size,  and  the  origin  of  numerous  im])oi'tant  nerves. 


THE    BRAIN    IN    AMPHIBIA,    REPTILES,    AND    BIRDS.  57 

In  amphibia,  the  brain  presents  a  smaller  cereljellum  than  in 
fishes,  corresponding  with  their  more  toi'pid  habit. 

The  reptilian  brain  difiers  from  that  of  fishes,  chiefly  in  the 
smaller  relative  size  of  the  optic  and  olfactory  lobes  and  cerebellum — 
the  latter  being  often  a  mere  delicate  transverse  band  across  the  upper 
part  of  the  medulla ;  and  in  the  relatively  large  size  of  the  cerebral 
hemispheres,  which  partly  overlap  the  optic  lobes  and  exhibit  a 
distinct  striate  body.  The  cerebellum  is  especially  large  in  the 
crocodile.  The  hemispheres  are  connected  as  in  fishes  by  an  anterior 
commissure. 

In  birds,  the  cerebral  hemispheres  exhibit  a  great  developmental 
advance.  They  are  very  large,  and  cover  more  or  less  completely  the 
Clitic  lobes.  The  cerebrum  contains  a  distinct  cavity,  corresponding 
to  the  lateral  ventricles,  and  communicating  with  the  hollOW 
peduncle  of  a  small  olfactory  lobe  in  front.  From  the  floor  is 
developed  a  gangliated  mass — the  corpuS  Striatum.  The  optic 
lobes  (corpora  bigemina)  are  two  smooth,  rounded,  egg-like  bodies,  just 
apparent  from  beneath  and  behind  the  hemispheres ;  widely  separated, 
but  communicating  through  a  hollow  passage  which  also  leads  into  a 
channel  between  the  third  and  fourth  ventricles.  From  below  we  see 
the  optic  nerves  arise  and  distinctly  decussate  aci'oss  the  middle  line. 
The  cerebellum  is  also  of  large  size,  but  chiefly  consists  of  the  middle 
lobe. 

The  germinal  area  of  the  mammalian  ovum  reveals  at  an  early  stage 
the  medullary  g'rOOVe,  as  a  longitudinal  and  gradually  deepening 
channel  in  the  fore-part  of  this  area — at  first  of  uniform  diameter 
throughout,  but  soon  becoming  widest  at  one  end — the  cephalic.  The 
groove  itself  results  from  the  thickening  of  the  outer  germ  layer  or 
epiblast  in  two  parallel  linear  streaks,  corresponding  in  direction  to 
the  long  axis  of  the  embryo.  The  thickening  of  these  parallel  ridges 
proceeds  until  the  groove  thus  produced  is  covered  in  by  the  bending 
across  and  coalescence  of  these  its  walls — the  so-called  medullary 
folds.  Thus,  the  medullai-y  groove  becomes  converted  into  the  closed 
canal  destined  to  become  the  cerebro-spinal  cavity,  and  now  termed 
the  neural  canal.  At  its  fore  end,  this  canal  is  dilated  into  a  bulb 
or  vesicle— the  primary  cerebral  vesicle;  whilst  shortly  afterwards 
two  other  vesicles,  separated  by  constrictions  of  the  neural  canal,  form 
along  this  end  of  the  canal  immediately  behind  the  first  vesicle.  These 
three  vesicles,  placed  one  behind  the  other,  lie  in  a  straight  line  with 
the  axis  of  the  neural  canal,  and  are  termed  respectively  the  VCSiclCS 

of  the  fore-brain,  the  mid-brain,  and  the  hind-brain. 

Vesicles  of  the  Fore-brain. — From  the  first  of  these,  a  lateral 
bulging  on  either  side  becomes  soon  apparent,  and,  steadily  increasing, 


58  THE    KNCEPIIALON — KMlJRYOLOfllCAL. 

is  lit  last  merely  connected  with  the  former  by  a  narrow  constricting 
neck  or  tubular  stalk.  These  give  origin  to  the  more  important 
structures  of  the  eye  and  are  termed  the  optiC  vesicles.  By  an 
exactly  similar  process,  two  other  lateral  bulgings  from  tlie  fore-part 
of  the  first  cerebral  vesicle  become  differentiated  therefrom  ;  and  these 
are  destined  by  rapid  growth  and  development  to  become  the  most 
important  and  conspicuous  parts  of  tlie  cranial  contents.     They  form 

the  cerebral  hemispheres  <>r  prosencephalon.    At  the  second 

month  of  intra-uterine  life,  they  are  mere  insignificant  AmpuUaj,  of 
somewhat  oblong  form;  but  even  now  presenting  a  short  tubular 
extension  from  their  tip,  which  is  the  rudiment  of  the  olfactory  lobe. 
The  remaining  portion  of  the  primary  vesicle  in  its  median  position 
enters  into  the  constitution  of  the  parts  around  the  third  ventricle. 
It  has  consequently  been  named  the  vesicle  of  the  third  ventricle,  or 
the  tween-hrain,  or  from  giving  origin  to  the  optic  thalami — the 
thalamencephalon.  Hence  the  two  pairs  of  vesicles,  the  optic  and 
hemispheric,  have  their  genetic  origin  from  the  thalamencephalon,  and 
a  direct  connection  between  these  structures  is  maintained  during 
all  later  stages  of  development.  The  cerebi-al  hemispheres,  as  offshoots 
from  the  primary  cerebral  vesicle,  are  hollow  vesicles,  communicating 
with  each  other  and  Avith  the  cavity  of  their  parent  vesicle,  the  third 
ventricle,  by  means  of  the  foramen  of  MonrO.  As  the  walls  of  the 
hemispheric  vesicle  gain  in  thickness,  its  cavity  becomes  of  course 
more  and  more  encroached  upon ;  yet,  for  a  long  period  during  uterine 
life,  the  growth  of  this  vesicle  is  so  rapid  tljat  its  cavity  is  of  great 
size ;  this  cavity  forms  therefore  a  relatively  capacious  ventricle — the 
lateral  ventricle.  In  the  outer  and  lower  wall  of  the  hemispheres 
thickening  proceeds  to  the  extent  of  forming  a  large  ganglionic  mass, 
the  corpora  striata  or  g'ang'lla  of  the  fore-brain.  These  ganglia,  it 
is  to  be  noted,  are  not  directly  derived  from  the  primal  neural  tube, 
but  from  an  offshoot  of  the  latter — the  hemispheric  vesicle.  The 
posterior  moiety  of  the  first  cerebral  vesicle  in  like  manner  exhibits  a 
thickening  of  its  walls,  which  form  the  ganglionic  mass  of  the  optic 
thalami,  connected  behind  by  the  posterior  covimissure,  just  above  which 
a  small  median  projection  forms — the  2^ineal  gland :  its  floor  upon  the 
other  hand,  sends  downwards  a  conical  projection — the  infundibulum, 

wliich  later  on  unites  with  the  hypophysis  cerebri  or  pituitary 

body,  immediately  over  the  pharynx  or  extreme  end  of  tlie  aliuu'utary 
canal.  The  funnel-shaped  extension  of  tlie  third  ventricle  is  by  some 
regarded  as  the  representative  of  the  neuro-enteric  canal,  which 
establishes  connection  directly  between  the  cerebral  and  caudal 
extremities  of  the  alimentary  canal  and  the  central  canal  of  the 
cerebi'o-spinal    system.      The    upper   part    or  roof  of  the    thalamen- 


DEVELOPMENT    OF    BRAIN-SEGMENTS    AND    FLEXURES.  59 

cephalon  becomes  thinned  out  into  a  mere  lamella  of  pia  mater, 
covering  tlie  tliird  ventricle  as  the  velum  interpositum. 

The  second  cerebral  vesicle  or  mid-brain  exhibits  no  such 

budding  off  of  secondary  parts  as  does  the  primary  vesicle;  its  upper 
hemisphere  becoming  thickened,  ultimately  forms  the  quadrigeminal 
bodies :  its  lower  hemisphei-e  or  floor  in  like  manner  develops  into  the 
crura  cerebri  or  cerebral  peduncles :  whilst  the  central  cavity  thus 
encroached  upon  becomes  eventually  reduced  to  an  exceedingly  narrow 
channel,  continuous  in  front  with  the  third  ventricle,  and  behind  with 
the  hollow  of  the  third  cerebral  vesicle — this  channel  is  the  sylvian 
aqueduct  or  iter  a  tertio  ad  quartum  ventriculum.  The  ganglia  of  the 
mesencephalon  or  corpora  quadrigemina  are  not  completely  differen- 
tiated until  the  sixth  or  seventh  month  of  inti'a-uterine  life.  At  the 
sixth  month,  a  vertical  groove  severs  the  vesicle  into  lateral  pairs ;  at 
the  seventh  month,  a  transverse  groove  separates  the  upper  pair  or 
nates  from  tlie  lower  pair  or  testes. 

The  third  cerebral  vesicle  or  hind-brain  becomes  differentiated 
into  two  segments — an  upper,  immediately  behind  the  corpora  quadri- 
gemina, from  which  is  derived  the  cerebellum,  pons,  and  upper  part  of 
the  fourth  ventricle  ;  and  a  lower,  forming  the  lower  half  of  the  fourth 
ventricle  and  medulla  oblongata.  The  roof  of  this  lower  segment 
thins  away  to  such  a  degree  that,  like  the  velum  interpositum,  it  also 
becomes  a  mere  membrane  closing  in  the  ventricle  at  this  site.  The 
upper  segment   is  termed  from    the   cerebellum   the   hind-brain  or 

epencephalon,  the  lower  segment  the  after-brain  or  meten- 
cephalon. 

The  Cranial  Flexures. — At  a  very  early  date,  the  first  cerebral 
vesicle  begins  to  curve  downwards  around  the  extreme  end  of  the 
notOChord,  until  from  being  in  a  line  with  the  latter  and  longitudinal 
axis  of  the  embryo,  it  becomes  placed  vertically  at  right  angles  to  this 
axis.  An  angle  or  bend  thus  occurs  between  it  and  the  middle  vesicle, 
which,  in  its  turn,  becomes  most  prominent  and  in  a  line  with  the 
notochord.  A  second  bend  in  consequence  of  this  flexure  also  occurs 
between  the  middle  and  the  posterior  vesicle,  or  that  portion  of  it 
which  becomes  the  cerebellum ;  a  third  takes  place  between  the 
latter  and  the  hinder  half  of  this  vesicle,  which  becomes  the  medulla 
Oblong'ata  ;  and  yet  another  between  this  region  and  the  commence- 
ment of  the  Spinal  Cord.  These  cranial  flexures,  which  occur  between 
the  first  cerebral  vesicle  and  its  derivatives,  tlie  Quadrigeminal  bodies, 
the  Cerebellum,  the  Medulla  oblongata,  and  the  Cord,  are  stated  by 
Tiedemann  to  take  place  about  the  seventh  week. 

In  the  further  process  of  development  the  cerebral  hemispheres 
or  prosencephalon  enlarge  wholly  out  of  all  proportion  to  the  hindt  r 


60  THE    CERKHIJAL    COUTKX. 

)):ii*ts  of  the  neunil  tulu',  so  (liiit  tlic  i|u;ulrii^(.'iiiiiiiil  luxlies  wliich 
hitherto,  as  in  iiniinals,  have  had  a  relatively  large  bulk  compared  with 
the  cerebrum,  become  now  placed  quite  in  the  shade  beside  the  rapid 
advance  made  by  the  cerebral  hemispheres.  They  extend  upwards  and 
backwards,  covering  and  concealing  the  thalamus  by  the  third  month, 
the  corpora  quadrigemina  by  the  sixth  month,  and  the  cerebellum  by 
the  seventh  month  of  intra-uterine  life.  Long  prior  to  these  last 
changes — in  fact,  about  the  fourlli  month,  a  slight  depression  appearing 
on  the  outer  as[)ect  of  each  liemispliere  midway  between  its  anterior 
and  posterior  extremity,  indicates  the  j^osition  of  the  sylvian  fossa; 
and  were  a  horizontal  section  of  the  liemisphere  carried  tlirough  this 
depression  we  should  find  the  walls  of  the  vesicle  within  much  thick- 
ened at  this  point,  the  thickened  mass  })votruding  into  the  central 
cavity  as  the  rudimentary  striate  g'ang'lia.  This  fossa,  which  is 
seen  early  in  all  mammalian  bniius,  becomes  the  insula,  island  of 
Reil,  or  central  lobe,  whilst  tlie  cortical  structure,  thickening 
around  it,  forms  a  distinct  fissure,  the  Sylvian  fissure,  Avhose  upper 
and  lower  margins  encroach  upon  and  cover  the  "island"  from  view. 
Up  to  the  fifth  month,  however,  the  fissure  of  Sylvius  remains  patent, 
exposing  the  island  to  view.  The  fissures  of  Rolando  often  appear 
about  the  end  of  the  fifth  month,  whilst  together  with  the  fissures  of 
the  frontal  lobe,  they  are  prominent  objects  on  the  surface  of  the 
hemisphere  at  the  termination  of  the  sixth  month  of  uterine  existence. 
About  the  same  time  also  appears  the  internal  parieto-occipital  fissure 
on  the  inner  aspect  of  the  hemisphere,  mapping  ott"  the  occipital  from 
the  parietal  lobe  on  its  median  aspect.  This  fissure  in  its  descent 
meets  tlie  hippocampal  fissure  at  the  point  wliere  its  posterior  exten- 
sion forms  the  so-called  calcarine  fissure. 


THE   CEREBRAL   CORTEX. 

The  fundamental  divisions  of  the  encephalon,  or  brain,  in  mammals 
are  identical  with  those  existing  in  the  whole  vertebrate  series  of 
skulled  animals  (Craniota).  The  early  history  of  embryonal  existence 
is  alike  for  all  —  each  animal  higher  in  the  scale,  even  the  highest — man, 
rei)roducing  at  an  early  period  of  embryonic  development,  as  a  tran- 
sient condition,  the  features  permanently  stamped  in  those  of  a  lower 
grade.  Tlie  infinite  degree  of  complexity  ultimately  obtained  by  the 
mammal's  brain  is  ])retigured  by  the  forms  assumed  in  the  lower  classes 
of  vertebrata,  and  depends,  for  the  most  part,  upon  tlic  preponderance 
of  certain  divisions  of  the  encephalic  mass  over  others,  and  also  upon 
the  growing   complexity   of  individual  parts,   either  as  the  result  of 


.'■■■=v^;;rf    '^  )<   ?: 


I  ^'x* ..   i. 


>-*;\ 


U  i>  >-„i 


»1  W'  ^"'f  ■ 


-^^ 


*^-  •'• 


CH]    Exira  Ir 

Liiiiiiil    Modvftei.  Upper  li 


Brain  of  Ra'o 
Mesial  aspect,  "basal  asv 
DistxiTD-ution    of    varioiLs 
nated  types  of  Corte: 


^ 


"Motor  Typ  e  " 

:dr?.-lir:i'^ic    are-,  cf  R-^btdt's  Bra-ji 


METHODS    OF    ENQUIRY.  61 

increasing  clifFei-entiation  of  existing  strnctnres  or  the  addition  of 
sujipleniental  parts  in  the  form  of  gaugliated  masses  or  fibrous  tracts. 
In  the  mammal's  brain  we  find  the  first  condition  exemplified  in  the 
complicated  convolutionary  surfaces  of  the  cerebrum  ;  in  its  division 
into  lobes  and  lobules;  in  the  wondrous  complex  structure  of  its 
cortex.  We  find  the  second  exemplified  by  certain  ganglionic  out- 
growths from  the  oi'iginal  bi'ain-vesicles,  and  along  its  fibrous  tracts  in 
the  large  striate  and  thalamic  ganglia,  in  the  lenticular  body,  the  optic 
basal  ganglion,  the  corpora  geniculata,  and  others ;  and  yet  again  in 
the  extreme  development  of  the  callosal  and  other  connecting  systems 
of  the  brain-mass.  The  endless  diversity  of  richly-convoluted  brains 
in  mammals  introduces  no  feeling  but  that  of  confusion  to  the  mind  of 
one  who  has  not  studied  the  cerebrum  in  its  various  forms  as  pre- 
sented by  the  whole  range  of  mammalian  animals  ;  in  fact,  a  compara- 
tive investigation  can  alone  teach  the  student  the  significance  of  its 
complicated  mantle,  and  help  him  towards  recognising  homologous 
parts  in  the  series. 

Great  advance  has  been  made  towards  this  end  by  the  labours  of 
Gratiolet,  Ecker,  Turner,  Broca,  Huxley,  who,  amongst  other  valuable 
results,  have  introduced  a  definite  nomenclature  which  reduces  to 
precise  terms,  universally  intelligible,  the  statements  of  different 
workers  in  this  department.  Another  field  of  enquiry  has  of  late 
added  rich  results  in  the  same  direction — the  physiological.  From 
that  epoch  in  the  historical  development  of  Nervous  Physiology  when 
it  was  discovered  that  the  cerebral  cortex  was  excitable  to  electric 
stimuli,  with  patient  toil  have  questions  been  pvit  and  answers  received 
by  this  method  of  research,  and  a  mapping  out  of  the  complicated 
fields  of  the  cortex  into  physiological  territories  established  by  Ferrier, 
Hitzig,  Horsley,  and  others.  Another  field  of  enquiiy  has  received 
but  scant  attention,  yet  it  is  one  which  an  accurate  scientific  know- 
ledge of  the  cortex  must  make  its  own  :  I  refer  to  the  histological 
structure  of  the  whole  cerebral  mantle  in  its  various  districts,  as 
supplemental  to  the  coarser  examination  of  its  medullated  tracts  by 
the  cleavage  methods  of  Gratiolet,  &c.  It  is  but  a  natural  a  prioi-i 
conclusion  that  differentiation  in  cerebral  function  implies  likewise  a 
structural  diflerentiation,  and  that  this  latter  is  one  of  qualitative  as 
well  as  qiiantitative  vali;e.  We  naturally  look  for  an  alteration  of 
structure  as  well  as  disposition  of  individual  elements,  and  the  increas- 
ing heterogeneity  of  such  individual  parts  we  regard  as  the  logical 
outcome  of  the  law  of  evolution. 

Thus  it  is  we  expect  the  physiological  areas  ascertained  by  Ferrier 
to  exist  in  the  brain  of  the  monkey  and  other  animals  to  exhibit  a 
structural  differentiation  characteristic  of  those  parts,  and  hence  to  be 


62  THE    CEREnRAL    CORTEX. 

helpful  in  the  recognition  of  analogous  regions  in  other  orders.  If  it  can 
be  established  that  areas  whose  functional  endowments  are  familiar  to 
\is  present  xiniformly  specialised  anatomical  features,  we  may  reasonably 
conclude  that  other  structui-ally  differentiated  areas  whose  functions 
are  unknown  to  us  at  present  nevertheless  have  each  and  all  of  them 
diverse  endowments.  An  attempt  to  delineate  the  homologous  areas 
of  the  cortex  in  the  different  orders  of  mammalia  by  simple  inspection 
would  (on  a  jn-ioi'i  grounds)  only  lead  to  failure ;  indeed,  errors  have 
already  been  frequently  committed  with  respect  thereto:  the  method 
of  physiological  experimentation  can  alone  lead  to  conclusive  results. 
But,  meanwhile,  we  should  not  neglect  the  important  consideration 
of  making  ourselves  acquainted  with  the  intimate  structure  of  the 
cortex,  wliich  also  has  its  own  special  significance,  and  which  would 
frequently  enable  us  to  avoid  the  error  of  drawing  our  analogies 
from  a  mere  superficial  resemblance  of  the  convolutionary  surface. 

The  grey  matter  enveloping  the  exterior  of  the  cerebral  hemispheres, 
the  cortex  cerebri,  merits  our  most  careful  stvidy,  as  being  pre- 
eminently the  site  of  those  deranged  functions  and  pathological  pro- 
cesses which  express  themselves  in  mental  disease.  Whatever  the 
limits  our  definitions  compel  us  to  impose  upon  the  sphere  of  con- 
sciousness, all  are  agreed  that  here,  in  the  wondrous  web  of  nerve 
cell  and  nerve  fibre,  take  place  those  activities  which  underlie  the 
conscious  states  we  denominate  mind.  It  becomes,  therefore,  an 
essential  part  of  the  training  of  the  student  of  Mental  Disease  to 
render  himself  practically  acquainted  with  the  structure  and  functions 
of  the  cerebral  cortex — the  "tissue  of  mind."  This  grey  envelope 
which  receives  the  terminal  extensions  of  the  ingoing  channels  of  com- 
munication with  the  outside  world,  on  the  one  hand,  and  forms,  on 
the  other  hand,  the  origin  for  the  outgoing  currents  of  the  same,  plays 
a  supreme  role  in  the  nervous  hierarchy,  and  to  it  all  other  centres  of 
grey  matter  are  subordinate.  In  the  human  brain,  the  cortex  is  con- 
tinuous all  over  the  hemispheres,  dipping  into  the  various  sulci  between 
its  convolutions,  and  terminating  at  the  median  constricting  ring 
through  which  the  bi-ain-stem  of  the  peduncles  passes  and  the  great 
commissural  tract  of  the  corpus  callosum. 

The  distribution  of  the  surface  into  intricate  convolutionar}'"  folds 
such  as  occur  in  man,  is  at  the  outset  somewhat  perplexing  to  the 
student.  Far  better  is  it  in  his  case  to  study  the  brain  of  some  of  the 
lower  animals,  which  present  a  smooth  non-convoluted  surface,  and 
gradually  extend  his  inquiries  to  the  convoluted  bi-ain  of  higher 
animals,  and,  lastly,  of  man.  Beginning  thus  with  the  simpler  forms 
of  life,  he  is  better  able  to  appreciate  in  the  wonderful  architecture  of 
even  these  simple  brains  the  profound  intricacy  of  the  nervous  centres 


NERVE-CELLS    OF    TUE    CORTEX.  63 

of  man  :  he  meets  with  fewer  obstacles  at  the  outset  to  discourage  his 
attempts,  and  he  lays  the  foundation  for  a  comparative  knowledge  of 
the  brain,  which  will  be  of  inestimable  value  to  him  in  his  subsequent 
studies. 

We  shall  adopt  this  plan  in  the  following  study  of  the  cortex  cerebri, 
and  commencing  with  the  brain  of  a  small  Rodent,  which  is  a  smooth- 
brained  animal,  take  the  Rat  as  our  illustration. 

Histological  Elements. — In  the  first  place,  what  are  the  elemen- 
tary constituents  of  the  cortex?  This  is  a  necessary  question  to 
dispose  of,  ere  we  pass  to  their  local  distribution,  regional  preponder- 
ance of  certain  elements  to  the  exclusion  of  others,  and  their  relation- 
ships to  underlying  tracts  of  medulla.  The  elementary  constituents  of 
the  coi'tex  are 

(a.)  Nerve  cells. 

(b.)  Medullated  and  non-medullated  nerve  fibres. 

(c.)  Connective  meshwork  of  "neuroglia  cell  and  fibre." 

(d.)  Blood- vascular  supply. 

(e.)   Lymphatic  supply. 

(a.)  Nerve  Cells. — The  nerve  cells  distributed  through  any  one 
part  of  the  cortex,  with  a  few  very  local  exceptions,  are  by  no  means 
identical  units  ;  a  vast  difference  is  observed  in  their  size,  contour, 
constitution,  connections,  their  locality  and  groupings  at  different 
levels;  and  it  is  upon  these  divergencies  that  we  base  our  classification 
of  such  elements  into  several  typical  forms.  With  respect  to  these 
cells,  authorities  are  at  variance — Luys,  Arndt,  and  Stephany  ad- 
mitting but  the  pyramidal  form,  whilst  Meynert  describes  three 
varieties — the  pyramidal,  the  granule,  and  the  spindle  form.*  We 
find,  however,  much  diversity  in  form — recognising  some  six,  if  not 
seven,  varieties ;  and  are  inclined  to  attribute  the  discrepancies 
between  difterent  writers  to  the  infrequent  examination  of  fresh 
frozen  sections  :  such  preparations  alone  reveal  the  typical  forms  of 
some  of  these  elements.  As  to  the  deforming  influence  of  chrome  re- 
agents in  the  preparation  of  sections  of  the  cortex,  we  have  elsewhere 
pi-actically  shown  the  necessity  of  checking  this  method  by  the  results 
obtained  by  means  of  sections  of  fresh  bi'ains.f  The  varieties  of  nerve 
cell  met  with  in  the  cortex  of  the  cerebrum  may  be  distinguished  into 
(1)  angular;  (2)  granule ;  (3)  pyramidal;    (4)  motor;    (5)  inflated  or 

*  "  The  Brain  of  Mammals,"  Theod.  Meynert,  in  Strieker's  Human  and  Com- 
parative Histology,  vol.  ii.     Psychiatry,  by  Theod.  Meynert,  transl.  by  Sachs,  p.  61. 
tSee  on  this  point  an  article  in  Brain,  vol.  i. 


64  THE    CKHKHKAL    CORTRX. 

globose  ;  (6)  spindle  cell.  Tliese  elements  can  be  readily  demonstrated 
in  the  different  regions  of  the  cortex  of  the  Rat  or  Rabbit,  which  the 
student  is  recoinniended  to  examine  as  comprising  within  a  small  space 
all  the  elements  described  in  this  section. 

(1)  The  ang'Ular  cell  is  of  very  irregular  contour,  occasionally 
ajiproaching  an  oval,  a  pyriforra,  or  even  a  fusiform  outline.  It  quite 
as  frequently  assumes  more  of  a  pyramidal,  and  still  more  frequently 
an  inverted  pyramidal  contoui-,  due  to  a  bicorned  formation  of  its 
iippermost  pole ;  in  fact,  its  distinguishing  feature  is  this  great  irregu- 
larity in  form.  These  cells  peculiarly  characterise  the  seCOnd  layeP 
of  the  cortex,  and  may  be  well  seen  in  the  g'reat  limbic  lobe  of  tlie 
Pig  or  of  the  Sheep.  To  see  its  more  notable  develojjment,  we  must 
turn  to  the  lower  arc  of  the  limbic  lobe  in  the  Rat  or  Rabbit,  or  what 
corresponds  to  the  gyrus  hippocampi.  Here,  within  the  area  limited 
by  the  limbic  sulcus  (Plate  i.,  a.t.c),  are  seen  dense  clamps  of  these 
irregularly-shaped  nerve  cells  closely  appressed,  usually  measuring 
18  II,  X  10  /A  in  size,  with  a  nucleus  of  9  /x  in  diameter.  An  important 
character  borne  by  these  irregular  elements  is  the  relatively  large  size 
of  the  nucleus,  as  compared  with  the  protoplasm  of  the  cell ;  this 
featui'e,  seen  in  these  elements  in  the  rodent,  in  the  sheep,  the  pig, 
and  other  mammals,  is  also  seen  in  the  cortex  of  man.*  In  OSmatiC 
mammals,  it  forms,  as  we  shall  see,  a  special  cortical  type,  and  we 
are  struck  further  by  the  dense  meshwork  of  ramifications  which  arise 
from  its  outermost  branches.  The  angular  cell  may  be  i-ecognised  at 
other  levels,  but  it  is  here  (gyrus  hippocampi)  that  its  richest  develop- 
ment occurs. 

(2)  The  granule  cell  is  a  small  element,  averaging  10//.  x  8  ,a  in 
size,  and  many  not  larger  than  9  //,  and  witli  a  nucleus  of  4  /x  to  5  /i  in 
diameter.  Slightly  conical  in  form,  with  relatively  large  nucleus,  the 
delicate  pi'otoplasm  extends  into  several  extremely  fine  processes  :  an 
apical  process  being  also  often  present.  This  element  forms  an  im- 
portant constituent  of  sensory  realms  of  the  brain,  and  may  be  seen  as 
a  densely  grouped  formation  in  what  we  have  elsewhere  described  as 
the  modified  upper  limbic  type  in  the  rodent  f  (Plate  iv.,  fig.  1). 
In  the  histological  study  of  the  cortex,  these  two  varieties  of  cell — the 
ang'Ular  and  the  g'Panule — are  so  diverse  in  forms,  and  their  regional 
distribution  is  so  distinct,  that  it  would  be  inexcusable  to  confuse  the 
two  formations  as  of  identical  constituents.     Meynert  aptly  compares 

*"The  Cortical  Lamiuation  of  the  Motor  Area  of  the  Brain,"  Proc.  Royal 
Soc,  No.  1S5. 

t"The  Comparative  Structure  of  the  Brain  in  Rodents,"  Philosoph.  Trans., 
partii.,  1882,  p.  709. 


GRANULE,  PYRAMIDAL,  AND  MOTOR  CELL.  65 

them  to  tlie  internal  gi-anule  layer  of  the  retina  and  the  elements  in 
the  gelatinous  nucleus  of  the  great  root  of  the  fifth  nerve,  or  of  the 
"granule  layer"  of  the  cerebellar  cortex.* 

(3)  The  Pyramidal  Cell.— From  its  uniform  contour,  large  size, 
very  general  distribution  (regional),  and  depth  of  formation,  this  cell 
has  come  to  be  I'egarded  by  many  as  pre-eminently  tJie  nerve  element 
of  the  cortex.  As  in  the  case  with  the  first  described  element,  the 
angular,  for  want  of  a  better  designation,  these  elements  are  likewise 
ill-named. 

Pyramidal  is  a  name  appropriate  only  to  those  cells  which  have 
undergone  the  corrugating  effects  of  chrome,  other  hardening  reagents, 
or  desiccation.  In  the  fresh  state  they  are  wholly  different  in  con- 
figuration from  those  seen  in  hardened  specimens.  On  the  other  hand, 
Meynert  is  far  too  exclusive  in  stating  that  their  true  form  is  that  of  a 
spindle;  in  fact,  they  are  very  variable  in  form,  often  plump  and 
rounded  ofi"  at  their  base,  lengthened  out  and  attenuated  at  their  apex. 
The  pyriform  contour  is  very  general — minute  angular  projections  of 
protoplasm  on  all  sides  mapping  out  the  origin  of  delicate  processes. 
Occasionally  they  are  elongated  and  truly  fusiform,  especially  in 
certain  definite  regions  of  the  cortex ;  and  yet  others  occur  where  the 
body  of  the  cell  is  larger  above  than  below,  its  base  being  in  fact 
attenuated,  so  that  the  cell  has  the  contour  of  an  inverted  ovoid. 
Where  they  approach  the  pyramidal  form  it  is  usually  one  of  a  very 
irregular  triangle,  with  sides  irregularly  broken  by  numerous 
dentations  caused  by  the  processes  distributed  therefrom.  From  the 
summit  of  the  cell  arises  the  apex  pPOCesS,  directed  radially  to  the 
surface  of  the  cortex,  whilst  on  either  side  from  the  basal  aspect  a 
fairly  stout  branch  diverges — not  at  right  angles,  but  forming  an  obtuse 
angle  (of  about  120°  very  uniformly)  with  the  long  axis  of  the  cell.  It 
appears  to  us  that  these  stout  lateral  branches  (which,  with  the  apical, 
form  by  far  the  most  prominent  extensions  of  the  cell)  explain  its 
triangular  or  pyramidal  form  upon  shrinking  in  chrome  fluids.  The 
basal  process,  a  fortiori,  is  far  less  clearly  delineated,  and,  as  before 
stated,  several  extremely  delicate  processes  may  arise  from  this,  the 
lower,  pole  of  the  cell.  It  is,  in  fact,  very  doubtful  whether  a  genuine 
axis-cylinder  process  is  developed  from  this  variety  of  cell,  as  we 
shall  see  is  the  case  with  the  larger  elements  underlying  them.  These 
bodies,  therefore,  throw  off  three  sets  of  fibres  : — 

(a.)  The  apical,  which  are  by  far  the  most  conspicuous,  and  always 
radiate  to  the  surface  of  the  cortex  ; 

(6.)  The  large  basal,  running  obliquely  outwards  and  downwards 
on  both  sides ;  and 

*  Op.  cit.,  1).  3S9. 

6 


66  THE   CEREliRAL    CORTEX. 

(c.)  Numerous  very  delicate  lateral  fibres  radiating  from  all  inter- 
vening districts  of  the  surface  into  the  nervous  meshwork  around. 

Each  cell  contains  an  oval  nucleus,  with  well-dolinod  nucleolUS, 
7 /i  X  5  ^  in  size.  The  dimensions  of  the  cell  vary  from  12/ji,x8//. 
in  tlie  more  suj)erlieial  to  41  //,  x  23  /a-  in  tlie  deeper  layex'S. 

(■i)  The  Motor  Cell. — We  are  alive  to  the  exception  which  may  be 
taken  to  any  Kuch  implication  as  the  above  designation  conveys;  yet, 
as  it  a])pears  to  us  that  the  argument  in  favour  of  their  motor  endow- 
ments has  been  materially  strengthened  l)y  farther  examination  of  the 
question,  we  prefer  this  designation  to  that  of  giant  pyramids, 
which  was  proposed  by  Betz,  more  especially  since  these  elements  may 
be  recognised  by  certain  features  in  certain  regions,  where  they  by  no 
means  deserve  the  epithet  ^^  giant  cell,"  being  even  smaller  than  the 
lower  cells  of  tlie  third  layer  above  them.  The  motor  cell,  taking  into 
consideration  the  more  characteristic  elements,  are  the  largest  cells 
found  in  the  cerebral  cortex.  Some  of  the  largest  of  these  measure 
126^1  in  length  by  55//.  in  the  shorter  diameter;  the  average  dimensions 
of  a  veiy  large  number  in  the  ascending  frontal  convolution  being 
GO  ijj  X  25  fjj.  The  extremes  are  30  fjj  and  96  /i.  for  length,  12  /x  and  45  /x 
for  breadth.  They  contain  an  oval  nucleus,  13-20  /x  in  greater  by  9-12  /i- 
in  lesser  diameter.  In  form  these  cells  are  very  variable,  usually 
much  swollen,  plump-looking  bodies;  they  are  elongated  and  attenuated 
towards  their  aj^ex  process,  throwing  off  the  gi-eater  number  of  processes 
from  near  the  opposite  pole.  The  contour  of  these  nerve  cells  appears 
related  to  the  number  and  size  of  their  branches — i.e.,  the  greater  the 
number  of  such  processes,  the  more  irregular  the  contour;  whilst  the 
apical  and  Ijasal  processes  being  i;sually  the  larger,  the  cell  tends  to 
lengthen  out  in  their  direction  and  assume  a  more  or  less  fusiform 
outline.  Large  processes,  howevei',  given  out  from  various  other 
points  of  the  cell,  gi-eatly  modify  this  spindle  form,  so  that  extreme 
variations  in  configuration  occur.  We  shall  see  that  we  have  reasons 
for  believing  that  the  primitive  form  of  all  these  nerve  cells  is  globose 
or  sliglitly  pyriform ;  that  the  fusiform  outline  is  the  next  stage  of 
their  development ;  and  that  further  modifications  occur  as  other 
processes  beyond  the  apical  and  basal  extend  laterally.  So  likewise  we 
shall  see  the  reverse  change  undergone  by  the  cell  in  the  dissolutions 
of  disease. 

The  cell  has,  in  the  normal  state,  no  cell-wall ;  but  the  appearance 
of  such  is  readily  induced  by  reagents  and  disease.  In  fresh  speci- 
mens obtained  from  frozen  brain,  the  coll  is  seen  to  consist  of  a 
delicate  protoplasm,  which  a]>pears  to  be  directly  continuous  with  its 
various  processes ;  nor  can  any  trace  of  the  fibrillated  structure  of 
the    ccll-contcuts    described    by    Max    Schultze    bo    detected    unless, 


PRIMARY    AND    SECONDARY    BRANCHES.  67 

indeed,  reagents  be  employed.  The  lower  pole  of  tlie  coll  is  usually 
pigrnented  as  a  normal  constituent,  just  as  is  the  case  with  the 
multipolar  cells  of  the  spinal  cord.  A  large  rouud  or  oval  nucleus 
enclosing  a  nucleolus  is  always  present  in  these  cells.  Each  cell 
throws  ofi"  what  may  be  termed  ppimary  and  secondary  branches — 
the  former  tlie  apical  and  basal  extension  ;  the  latter  including  all 
other  processes,  whether  coarse  or  fine  delicate  fibres.  The  apex 
process,  formed  by  the  gi-adual  attenuation  of  the  cell,  passes  straight 
up  through  the  superjacent  layers  of  cells,  and  can  be  often  traced  into 
the  first  or  peripheral  cortical  layer,  where  it  becomes  lost  to  view  ; 
we  shall  refer  to  its  destination  further  on.  Since  in  the  motor  cortex 
these  nerve  elements  are  aggregated  into  groups  or  clusters  (Plate  ii., 
fig.  1),  these  apical  processes  closely  approximated  often  run  in  sheaves 
through  the  more  superficial  layers.  The  basal  prOCeSS  often  arises 
in  like  manner  from  a  gradual  attenuation  of  the  opposite  pole,  as  in 
the  fusiform  cells,  and  large  lateral  branches  may  strike  out  from  this 
extended  pole.  The  basal  process,  however,  continues  downwards  for 
some  distance,  when  it  gains  a  thin  investing  sheath  of  medulla,  which, 
gradually  thickens  upon  it,  converting  it  into  a  true  medullated  nerve 
fibre.  Hence  this  process  is  called  the  axis-cylindeP  prOCesS.  As 
Meynert  remarks* — "It  is  the  more  rarely  seen  because,  being  the 
process  which  enters  the  medulla,  its  direction  is  dependent  on  the 
angles  formed  by  the  fasciculi  of  the  latter,  which  by  no  means  form  a 
straight  line  with  the  apical  process  of  the  pyramid."  This  obliquity 
of  position,  therefore,  necessitates  its  being  cut  ofi"  in  sections  on  a 
plane  with  the  radiating  apical  processes. 

The  secondary  or  lateral  processes  which  radiate  from  the  cell 
on  all  sides,  unlike  the  former,  divide  and  subdivide  almost  immediately 
after  their  origin,  and  interlace  in  the  intricate  webwork  of  nerve  and 
connective  fibre  around  the  cell.  We  are  apt  to  overlook  the  extreme 
complexity  of  structure  in  vertical  sections  of  the  cortex,  and  should 
compare  with  such  sections  others  carried  across  the  long  axis  of  the 
cell  (obtained  by  placing  the  cortex  surface  downwards  on  the  freezing 
microtome,  and  cutting  down  to  the  level  of  these  cell  groups).  Such 
sections  show  us  one  or  two  cells  as  the  centre  of  an  area  to  which  their 
branches  are  distributed  ;  their  finest  ramifications  apparently  blending 
with  those  from  adjacent  cell  territories.  We  have  observed  as  many  as 
eighteen  main  processes  divei'ge  from  a  single  cell  in  such  sections ;  in 
vertical  sections  the  average  number  seen  is  about  seven,  but  as  many 
as  fifteen  have  been  observed.  When  it  is  remembered  that  no  single 
section  can  show  (as  the  teazing  methods,  however,  do)  the  actual 
number  of  branches  in  any  single  cell,  the  above  statements  will 
*  The  Brain  of  Ifamniah,  Strieker's  Handbook,  p.  3S7. 


68  TIIK    CEUKBRAL    COUTKX. 

indicate  the  wealth  of  communicating  brandies  which  these  "  motor 
units  "  possess. 

Wlien  we  come  to  examine  what  appear  to  be  the  corresponding 
cells  in  the  cortex  cei'cbi-i  of  some  of  the  lower  mammals,  we  find 
certain  strong  jjoints  of  resemblance,  together  with  certain  distinctive 
features  by  which  we  may  very  readily  recognise  them  as  not  human. 
Thus  in  the  pig",  in  lieu  of  the  great  irregularity  in  marginal  contour 
seen  in  man,  we  observe,  on  the  contrary,  a  notable  uniformity  of  con- 
tour, the  elongate  pyramid  being  the  almost  universal  form.  "They 
resemble  closely,  both  in  size  and  form,  the  large  pyramidal  cells  at 
the  deepest  portion  of  the  third  layer  in  bimana,  quadrumana,  and  the 
large  carnivora,  as  also  the  ganylionic  cells  in  the  parietal  and  temporo- 
sphenoidal  lobes  of  man.  Nowhere  do  we  find  the  irregulai",  swollen, 
and  at  times  almost  globose  cells  so  frequent  in  the  motor  area  of  the 
human  brain."  *  Again,  in  the  sheep,  w-e  fail  to  find  the  plump 
rounded  cells  of  man  and  the  higher  mammals;  but  the  cell  is  more 
variable  in  form  than  in  the  pig,  the  elongated  pyramid  being  inter- 
spersed freely  with  long  spindle  forms  and  large  numbers  of  a  peculiar 
'*  hOPned"  cell,  in  which  the  apex  process  is  bifurcate  at  its  origin 
near  the  cell.  They  measure  on  an  average  46  /a  x  11  /a.  In  the 
cat,  however,  these  elements  are  plump,  oval,  and  pyriform ;  average 
51  /i  X  21  /A  in  size,  with  an  occasional  gigantic  cell  of  lOG  //.  x  32  /a  j 
and  are  grouped  together  in  well-marked  clusters.  In  the  rodent 
(rat,  rabbit)  the  type  of  cell  approaches  that  found  in  the  sheep 
and  pig. 

One  may  readily  perceive  the  remarkable  resemblance  between  these 
cells  and  those  of  the  anterior  cornu  of  the  cord  in  chrome-hardened 
preparations,  but  still  closer  appear  their  affinities  in  structural 
arrangements  when  teazed-out  specimens  of  brain  and  coi'd  are  com- 
pared. The  inference  that  these  cells  are  s])ccialised  elements  rests  on 
this  resemblance,  on  the  possession  of  an  axis-cylinder  process,  on  their 
exceptionally  large  size  and  abrupt  commencement,  and  the  peculiar 
clustered  groupings  assumed  in  a  region  which  has  been  shown  by 
Fen-ier  to  possess  motor  endowments.  Meynert,  on  the  other  hand, 
who  fails  to  recognise  these  larger  cells,!  draws  a  parallel  between  the 
whole  of  the  pyramidal  cells  of  the  third  layer  and  the  motor  cells  of 
the  cord.  His  statement  is  as  follows  : — "  If  we  remember  that  the 
anterior  roots  of  the  spinal  cord,  at  their  origin  in  the  anterior  cornua, 

*  "Researches  on  the  Comparative  Structure  of  the  Cortex  Cerebri,"  Proc.  Fioy. 
Soc,  parti.,  1880. 

t  See  the  diagram  of  the  five-layer  type  in  Meynert'3  Psychiatry,  and  also  in 
Sydenham  Society's  Trans,  of  his  monograph,  fig.  234. 


THE  INFLATED  OR  GLOBOSE  CELL.  69^ 

are  connected  with  elements  which,  through  tlie  slenderuess  of  their 
bodies,  the  gradual  transition  of  these  bodies  into  the  protoplasm  of 
the  processes,  and  the  greater  number  and  size  of  the  latter,  are 
sharply  differentiated  from  the  cells  in  which  the  posterior  roots 
originate  in  the  interspinal  ganglia,  these  being  tumid  and  provided 
with  few  and  attenuated  processes,  an  affinity  in  point  of  form  is  at 
once  seen  between  the  pyramids  of  the  cortex  and  the  former,  which  is 
common  also  to  the  cells  of  origin  of  all  motor  cerebral  nerves,  and 
permits  an  analogy  to  be  drawn  in  regard  to  the  significance  of  the 
pyramids  of  the  cortex.  "  * 

(5)  The  Inflated  or  Irreg'ulaply  Globose  Cell. — The  nerve  cell 

to  which  the  ejiithet  inflated  has  been  given  has  not  been,  so  far  as 
we  are  aware,  described  amongst  the  constituents  of  the  cerebral 
cortex  by  any  former  writers  on  the  subject.  We  first  drew  attention 
to  it  as  a  specialised  cell,  forming  a  distinct  layer  of  the  cortex,  in  a 
Memoir  on  the  Comparative  Structure  of  the  Brain  in  Eodents  (1882), 
and  subsequent  examinations  fully  confirm  the  description  then  given. 
The  brain  of  the  mole,  rat,  or  rabbit  is  especially  suitable  for  demon- 
strating the  presence  of  this  element.  The  cell  which  occupies  the 
position  of  the  small  "  pyramidal "  and  angular  .bodies  of  the  second 
layer  is  no  longer  of  pyramidal  form,  but  swollen,  inflated,  globose,  or 
flask-shaped,  and,  moreover,  oi  far  greater  size.  The  average  dimensions 
attained  by  it  are  37  /i  x  33  /i,  with  a  nucleus  of  13  /a  ;  some  are  more 
elongate,  measuring  46  /a  x  27  (m.  Hence,  these  elements  are  more  than 
double  the  size  of  those  usual  to  this  position,  and  exhibit  the  apparent 
anomaly  of  large  cells  in  the  cortex  superimposed  on  a  layer  of  small 
pyramids.  The  region  in  which  they  are  found  is  really  tlie  hindmost 
extension  of  the  lower  limbic  lobe  (modified  lower  limbic  type)  in  the 
rodent. 

As  will  be  seen  later  on,  the  second  layer  of  the  coi'tex  in  the  lower 
limbic  arc  is  characterised  by  its  peculiar  closely  appressed  clusters 
of  small  pyramidal  or  angular  elements,  with  bifurcate  apices,  which 
subdivide  into  a  dense  meshwork  of  fibres ;  farther  back,  in  the  region 
above  indicated,  these  elements  appear  transformed  into  the  inflated 
cell,  retaining,  however,  their  bifurcate  aj)ices  and  plexiform  bi'anching. 
The  cell  throws  ofi"  numerous  fine  pi'ocesses  on  all  sides;  its  proto- 
plasm— exceedingly  delicate — shrinks  greatly  under  the  influence  of 
alcoholic  and  other  corrugating  reagents,  and  should, therefore,  be  always 
examined  in  the  fresh  state.  When  acted  upon  by  chrome  it  loses  its 
chai-acteristic  appearance  and  resembles  the  vesicular  cell,  which,  in  the 
medulla  and  spinal  cord,  is  regarded  as  possessing  sensory  endowments. 

*  Brain  of  Mammals,  p.  3S7. 


70  THE    CEREBRAL    CORTEX. 

It  appears  to  us  that  tlic  whole  belt  of  the  second  layer  of  the  cortex, 
out  of  which  this  specialised  cell  is  developed,  may  subserve  the 
same  purpose — that  of  sensation  in  its  various  phases  :  the  evidence 
on  this  point  had  better  be  considered  at  a  later  stage  of  our 
enquiries. 

(6)  The  Spindle  Cell. — This  undoubtedly  is  also  a  specialised 
element.  The  cell  is  a  narrow  fusiform  body,  attaining  the  average 
dimensions  of  25  /x  x  9  [i,  the  largest  being  32  /a  x  13  /a,  with  an  oval 
or  fusiform  nucleus  11  /«-  to  13  /^  in  length  x  6  /^  to  9  />!/  in  bi'eadth.* 
Their  two  principal  branches  arise  from  either  pole  so  as  to  give  them 
in  many  cases  the  aspect  of  bipolar  cells;  but,  as  indicated  by  Meynert, 
lateral  projections  also  arise  from  these  bodies.f  Frequently  this 
lateral  branch  becomes  large,  and  the  resulting  angular  projection  of 
the  cell-protoplasm  into  it  gives  the  cell  a  triangular  or  triradiate 
form.  The  cell  is  regarded  as  an  intercalated  element  of  the  connecting 
system  of  the  brain,  and  since  the  claustrum  is  entirely  composed  of  such 
elements,  the  term  claustral  formation  has  been  proposed  for  it  by 
Meynert.  These  elements  are  peculiarly  prone  to  a  nuclear  prolifera- 
tion, which  occasionally  accumulates  into  little  heaps  almost  concealing 
these  cells  from  view.  In  position  they  underlie  the  other  layers  of 
the  cortex  throughout  its  whole  extent ;  whatever  be  the  type  of 
lamination,  the  lowest  stratum  will  always  present  us  with  these 
spindle  cells  of  the  association  system  of  the  bx-ain ;  this  applies 
equally  to  the  mammalian  brain  in  generah 

We  have  elsewhere  indicated  the  existence  of  a  perfectly  g'lobose 
cell — with  a  single  delicate  apex  process,  and  two  or  more  extremely 
attenuated  processes — without  any  angular  pi'ojections  from  the  cell, 
but  a  perfectly  uniform  rounded  contour — as  existing  normally  in 
the  second  and  third  layers  of  the  cortex  of  the  ape,  and  as  being 
specially  characterised  by  this  swollen  globose  contour,  and  great 
paucity  of  branches.  They  are  met  with  in  man  only  in  forms  of 
developmental  ai-rest — in  idiotcy  and  imbecility ;  but  elements  which 
remind  us  of  these  cells,  occur  in  the  second  layer  of  the  cortex  of  the 
pig.  These  may  be  early  stages  in  the  development  of  the  more 
advanced  forms  of  cortical  cells,  and  may  or  may  not  have  affinities 
to  the  inflated  irregularly  globose  elements  already  desci'ibed  in  a 
specialised  cortex  of  the  rodent. 

The  above  constitute  the  various  forms  of  nerve  cell  which  occur  in 
the  mammalian  cortex,  and  we  must  now  direct  attention  to  its  other 
histological  constituents  :  these  consist  of— « 

*  Transactions  of  the  Roy.  Soc,  1SS2,  part  ii.,  pp.  714-15. 
t  Op.  cit.,  p.  3S9. 


K. 


J         of  seconc- 


:■  t^ 


•^       t^i  erve -etsmeivts  c 


i-lP/i. 


i-tpx    r,f  pi -> -left  Iveraisv- '•-:•- 

■';K  the  Nei.-.. 
IS.  X76. 


-__    -r    -Di 


PRIMITIVE    FIBRIL — NON-MEDULLATED    FIBRE.  71 

(a.)  ISTerve  fibres ; 

(/».)   Blood-vessels ; 

(c)   Connective  matrix  or  neuroglia  ; 

(d.)  Lymph  channels. 

(n.)  Nerve  Fibres. — As  is  well  known,  nerve  fibres,  central  and 
periphei'al,  present  varied  forms,  corresponding  to  five  stages  of  deve- 
lopment— from  the  viltimate  fibril  up  to  the  enslieathed  and  medullated 
fibre  of  the  peri]>heral  nerve  trunks.  The  last,  the  most  perfect  and 
complex  form,  does  not  occur  in  the  nerve  centimes  at  all.  In  the 
cortex,  as  well  as  the  nervous  centres  generally,  three  forms  of  fibre 
are  met  with — (1)  The  primitive  fibi'il.  (2)  Naked  axis-cylinder  or 
protoplasmic  process.  (3)  The  medullated  fibre  devoid  of  a  sheath  of 
Schwann. 

(1)  The  Primitive  Fibril.  —  The  representative  of  the  ultimate 
divisions  of  the  non-medullated  fibre,  is  an  excessively  delicate 
attenuated  thread,  revealed  only  by  an  amplification  of  500  diameters ; 
and  which,  as  the  result  of  post-mortem  change,  becomes  beaded  or 
shows  varicosities  along  its  length.  They  are  observed  readily  from  the 
occurrence  of  this  change  by  lower  powers  of  the  microscope  (  x  350), 
especially  by  imbibition  of  fluid  around,  which  causes  them  to  swell 
up  into  large  oval  varicosities.  Such  delicate  beaded  threads  are  seen 
at  all  depths  of  the  cortex  in  fresh  sections  obtained  from  frozen  brain, 
treated  with  osmic  acid,  '25  per  cent.,  and  protected  by  a  cover-glass  ; 
but  they  are  also  traceable  in  sections  which  have  been  hardened  by 
chrome,  especially  in  the  lowermost  layers.  They  are  seen  in  many 
cases  to  arise  from  the  subdivision  of  larger  fibres;  they  are  perfectly 
homogeneous,  betraying  no  internal  structure  to  the  highest  powers  of 
the  microscope. 

(2)  The  Naked  or  Non-Medullated  Fibres,  also  called  the 
naked  axis-cylinders,  the  protoplasmic  processes  of  Deiters, 

form  an  important  constituent  of  the  cortex.  From  what  has  already 
been  stated  I'especting  the  mode  of  branching  of  the  nerve  cells,  it  will 
be  apparent  that  the  protoplasmic  extensions,  which  form  these  naked 
axis-cylinders,  occur  in  complicated  meshwoi-ks  throughout  the  cortex. 
To  this  category  really  belong  both  primary  and  secondary 
branches  (p.  G7)  of  the  nerve  cell  in  the  fii'St  portion  of  their 
course ;  but,  since  their  destination  is  wholly  diff"erent,  so  their  con- 
stitution differs  at  a  subsequent  stage.  The  apical  ])rocess  and 
lateral  extensions  pass  by  subdivision  into  an  intricate  meshwork 
of  fibrils:  the  basal  process  becomes  invested  lower  down  with  a  pro- 
tecting layer  of  medulla.  This  is  the  process  to  which,  properly, 
should  be  restricted  the  term  axis-Cylinder  prOCeSS ;    and,  for  all 


72  THE    CEREBRAL   CORTEX. 

otlicr  extensions  of  the  cell  protoplasm,  the  term  non-medullated 
fibre  or  protoplasmic  processes  should  be  applied  in  lieu  of  naked 
axis-cylinder.  iSucli  processes  are  very  variable  in  size;  but,  at  their 
origin  from  the  various  cells  of  the  cortex,  they  range  between  1  (l 
and  6  /«.  in  diameter :  the  lateral  processes  in  particular  become 
rapidly  attenuated  by  subdivision,  but  yet  may  be  occasionally  traced 
over  very  lengthy  tracts :  the  apex  processes,  running  to  the  upper- 
most layer  of  the  cortex,  may  often  be  traced  to  their  termination 
here. 

These  fibres  exhibit,  under  certain  conditions  of  examination,  a 
linear  longitudinal  marking,  which  has  been  described  as  "  fibrilla- 
tion"  by  certain  autliorities  [Max  Schultze,*  Landois  and  Stirling  \): 
the  homogeneous  nature  of  the  non-medullated  fibre  and  axis-cylinder 
has,  on  the  other  hand,  been  maintained  by  K'uUiker,'^  Waldeyer,^  and 
others.  Since  those  who  support  the  view  of  the  fibrillation  of  the 
axis-cylinder  regard  the  fibi'e  as  a  compound  of  the  ultimate  fibrils 
already  described,  separated  by  a  small  quantity  of  interfibrillar  sub- 
stance, and  believe  them  to  be  continuous  thi'ough  the  ganglion  cell  in 
what  they  describe  as  a  well-marked  fibrillation  of  its  interior,  the 
question  of  the  homogeneity  or  of  the  fibrillated  constitution  of  the 
axis-cylinder  V)ecomes  of  fundamental  importance  in  neurology.  Such 
fibrils  would  be  regarded  as  isolated  tracts  of  conduction  throughout 
their  length,  the  nerve  fibre  itself  being  a  far  more  complex  structure 
than  what  it  was  once  regarded  as  being,  and  the  cell  itself  would 
have  a  far  different  significance.  Nor,  according  to  some,  need  this 
visible  conlinuitij  of  the  fibrillar  be  demanded  to  establish  the  case — 
more  or  less  fusion  may  occur  thi'oughout  the  length  of  the  fibre; 
and  the  splitting  up  into  fibrillar  only  be  observed  at  the  centi'ic  and 
peripheric  terminations  as  an  indication  of  the  fibrillar  constitution  of 
the  axis-cylinder  and  its  lines  of  molecular  disturbances.  If  these 
protoplasmic  pi'ocesses  and  axis-cylinders  be  submitted  to  the  action  of 
silver  nitrate  in  the  dark,  subsequent  exposure  shows  them  to  be  marked 
by  a  ])eculiar  transverse  striation,  first  indicated  by  Fromann.  ||  Their 
significance  is  unknown. 

(3)  Medullated  Fibre  or  Axis-cylinder  Process.— This  may 

be  either  examined  in  tlie  radiating  expansion  arising  from  the  medul- 
lated core  of  a  convolution  at  the  site  of  the  spindle  layer  of  cells ;  or, 
in  the  different  intracortical  arciform  belts  found  at  a  higher  level. 

*  Strieker's  Human  and  Comparative  Hidologn,  Syd.  Soc.,  p.  158. 

t  Test- Book  of  II u man  I'/n/siolorj)/,  vol.  ii.,  p.  768. 

+  Gewehelehre,  6th  Aufl.,  1867,  p.  244. 

§  Zeituchrift  Jiir  Balionelle  Medicin,  Band  xx.,  1863. 

II  Virchow's  Archiv,  Band  xxxi. 


MKDULLATED    XERVE-FIBRES.  73 

The  medullated  fibre  of  brain  and  spinal  cord  consists  simply  of  an 
axis-cylinder  with  an  investing  sheath  of  myelin,  which  gives  to  the 
medullated  fibre  its  white  appearance,  non-meduUated  fibres  having  a 
grey  translucency.  The  myelin  is  of  fluid  consistence,  and  appears 
limited  simply  by  a  very  friable,  soft,  protoplasmic  envelope  [Cornil 
and  Ranvier  *),  and  not  by  the  strong  resisting  sheath  (of  Schwann) 
which  invests  the  peripheral  fibres.  Kiihne  and  Ewald  have  proved, 
by  the  use  of  trypsin,  that  the  axis-cylinder  is  enclosed  in  a 
sheath  of  indigestible  horny  matexial,  which  they  term  the  keratoid. 
sheath.  In  the  peripheral  nerves,  however,  this  keratoid  sheath  not 
only  embraces  the  axis-cylinder,  but  being  reflected  on  the  inner 
aspect  of  the  sheath  of  Schwann,  really  serves  to  enclose  the  white 
medullated  substance  or  myelin.  In  these  more  complex  peripheral 
fibres  (to  which  we  must  divert,  for  the  time,  our  attention),  although, 
the  axis-cylinder  is  continuous  throughout,  the  medullaiy  sheath  is  not 
so,  but  presents  at  regular  intervals  annular  constrictions  named 
RanvieP'S  nodes,  after  their  discoverer.  Eanvier  called  the  in- 
dividual parts  formed  by  these  constrictions  interannular  Seg"- 
ments ;  and  showed  that,  whilst  covered  externally  by  the  resistant 
structureless  sheath  of  Schwann,  both  were  interrupted  at  these 
constrictions.  In  a  depression  of  the  myelin,  and  between  it  and  the 
sheath  of  Schwann,  are  the  nerve  COPpuSCleS — one  for  each  segment, 
consisting  of  an  oval  nucleus  surrounded  by  a  little  protoplasm. 

The  neuro-keratin  sheath,  spoken  of  above,  lies  therefore  on  the  axis- 
cylinder,  and,  reflected  at  each  constriction  upon  the  sheath  of  Schwann, 
enjoys  the  same  segmentation  as  the  other  constituents  of  the  nerve 
fibre.  Traversing  the  medullated  substance  from  the  inner  to  the 
outer  portion  of  the  keratin  sheath,  are  numerous  transverse  and 
oblique  dissepiments,  also  of  a  horny  nature,  supporting  the  myelin 
(Lantermann).  At  the  annular  constrictions,  there  exists  a  certain 
amount  of  cementing  mateiial,  which,  when  the  fibres  are  treated  with 
silver  nitrate,  becomes  darkened,  and  appears  as  a  small  cross  at  these 
nodal  points  along  the  fibres.  The  silver  penetrating  at  these  nodes  stains 
also  the  axis-cylinder  to  a  very  limited  extent,  producing  Fromann's 
lines.  It  is  at  this  site  that  nutritive  fluids  gain  access  to  the  axis- 
cylinder,  which  otherwise  could  not  be  reached  through  the  keratin 
sheath  and  medulla.  Here  also  staining  reagents  gain  admission,  and 
colour  the  axis;  and  the  myelin,  after  imbibition  of  fluid  by  the  fibre, 
exudes  at  these  constricting  rings,  pressed  out  by  the  swollen  axis- 
cylinder  in  the  form  of  droplets,  easily  recognised  by  their  spherical 
form  and  double  contour. 

The    medullated    fibre    of    the    central    nervous    system,    however, 
*  Pathological  Histologi/,  vol.  i.,  p.  33.     Trails,  by  A.  M.  Hart. 


74  THE   CEREBRAL   CORTEX. 

possesses,  as  we  have  already  remarked,  no  sheath  of  Schwann ;  it  is 
consequently  devoid  of  the  constrictions  or  nodes  of  Kanvier,  has  no 
interannular  segments,  no  nuclei  along  its  length,  nor  does  it  exhihit 
any  signs  of  lianvier's  cross  on  treatment  by  silver  nitrate.  The 
constitution  of  tliese  centric  raedullated  fibi-es,  therefore,  leads  to  a 
more  pe7'ishable  nature.  They  are  /ar  less  resistant  than  those  of  the 
peripheral  nerves,  break  up  more  readily  into  myelin  spheres,  or 
become  extensively  varicose.  Hence,  also,  we  find  it  difficult  to  stain 
such  medullated  fibres  in  fresh  brain.  The  protoplasmic  extensions,  or 
naked  axis-cylinders,  take  up  aniline  dye  readily,  becoming  stained  of 
a  deep  blue-black ;  but,  where  the  medullated  sheath  intervenes,  the 
reagent  fails  to  penetrate  except  along  a  short  length  just  beyond  the 
first  appearance  of  the  sheath.  This  want  of  permeability  is  compen- 
sated for,  as  before  stated,  in  peripheral  fibres  by  the  presence  of  the 
constrictions  of  Ranvier. 

To  stain  the  axis-cylinder  tliroughout  its  length  in  these  centric  fibres, 
we  must  first  displace  the  myelin.*  This  can  be  eftected  by  prolonged, 
immersion  of  the  section  in  water,  and  subsequent  staining  with 
aniline  blue-black.  Twelve  hours'  immersion  usually  sufiices  to 
remove  the  whole  of  the  medulla  around  the  axis-cylinders ;  and.  the 
latter  are  then  seen  as  slightly  wavy,  swollen  bands,  often  strap-shaped, 
and  occasionally  contorted,  from  the  alteration  undergone  by  aqueous 
immersion.  They  all  run  from  the  coi'tex  downwards  into  the  core  of 
the  medulla,  to  which  they  conA'erge  in  large  numbers — deejily  stained; 
and  forming  a  striking  conti'ast  to  the  unstained  aspect  of  nerve 
elements  at  this  site  in  sections  which  have  been  prepared  in  the  usual 
manner.  But  although  such  axis-cylinders  present  difficulties  in 
staining  along  their  length,  they  are  well  seen  in  sections  across  their 
axis:  such  cross-sections  appearing  especially  in  the  lowest  layers  of 
the  cortex  (spindle-cell  layer)  as  a  central  dark  axis  (often  slightly 
drawn  out  into  a  short  filament),  surrounded  by  a  sheath  of  white 
medulla  retaining  its  circular  outline  —  the  myelin  having  been 
apparently  "fixed"  by  the  osmium  treatment.  The  medulla  in  these 
cases  is  not  perfectly  homogeneous,  but  has  undergone  a  change  which 
gives  it  ix  frosted  vitreous  aspect,  with  a  very  slightly  granular  appeai-- 
ance,  the  diameter  of  the  fibre  being  from  three  to  four  times  that  of 
the    axis-cylinder.t       Large  medullated   fibres  occur  at   this  site,    in 

*  lu  the  very  ininute  medullated  fibres  of  the  cortex,  we  have  an  exception  to 
this  rule — the  axis-cylinder  staining  fairly  well  without  displacement  of  its 
investing  myelin  sheath :  a  result  due  undoubtedly  to  the  small  calibre  of  the  latter 
allowing  a  certain  amount  of  permeability. 

t  It  must  be  borne  in  mind  that  there  exists  a  certain  definite  relationship 
betwixt  diameter  of  axis-cylinder  and  medullated  sheath :  the  larger  axis-cylinder 
always  having  a  larger  sheath  and  vice  versa. 


HISTOLOGY    OF    ARTERIAL   TUNICS.  75 

section,  measuring  13  ,a  across,  with  an  axis-cylinder  of  4  /x ;  but 
extremely  minute  fibres  are  seen  intermingled  with  these  larger  forms 
also,  if  the  field  be  carefully  searched.  As  we  shall  see  later  on, 
certain  morbid  conditions  of  the  cerebral  cortex  modify  to  a  con- 
siderable extent  the  character  of  this  investing  medulla. 

(6.)  Blood-vessels  of  the  Cortex— (l)  Arteries.— These  vessels, 

as  they  dip  into  the  cortex,  vary  in  dimensions  irom  4  /i  to  12  /a. 
They  possess  the  tliree  tunics  which  are  recognisable  to  the  naked 
eye  in  large  arteries  elsewhere,  the  tunica  adteutilia,  media,  and 
intima;  but,  as  in  these  lai-ger  vessels,  microscopic  examination 
reveals  the  fact  that  each  of  these  tunics  is  separable  into  several 
difterently-constituted  layers,  so  the  larger  cortical  blood-vessels 
exhibit  in  the  innei'most  coat  a  double  layer — an  elastic  and  an 
endothelial  layer. 

The  intima,  or  lining  membrane  of  the  artery,  in  the  fresh  state 
appears  as  a  structui'eless  membranous  tube,with  numerous  oval  nuclei, 
well  seen  in  carmine-stained  preparations,  scattered  over  its  surface. 
These  niiclear  elements  are  disposed  longitudinally,  i.e.,  in  the  direction 
of  the  vessel's  length.  The  action  of  a  solution  of  silver  nitrate  (i  per 
cent.)  reveals  the  fact  that  this  tunic  is  not  a  homogeneous  tube,  but 
that  it  is  constituted  of  large  squamous  endothelial  cells,  which  look 
like  polygonal  flattened  scales,  united  to  each  other  at  their  mai-gin 
by  a  cementing  material,  which  is  mapped  out  in  black  lines  by  its 
reduction  of  the  silver  salt.  Moreovex",  it  is  then  seen  that  the  oval 
carmine-stained  elements  are  nuclei  of  these  flattened  cells.  The 
inner  elastic  tunic  is  in  the  smallest  vessels  a  structureless  mem- 
brane, seen  as  a  bright  wavy  division  between  the  endothelial  and 
muscular  coat  in  transverse  sections  of  the  vessel;  in  the  larger 
arteries  it  is  a  distinctly  fenestrated  membrane,  the  representative 
of  Henle's  fenestrated  and  elastic  laminte,  which  can  be  stripped 
ofi"  in  shreds  from  great  arterial  trunks  like  the  carotid  and  axillary 
when  they  tend  to  curl  at  the  edge  and  roll  themselves  up.  It 
forms  an  important  line  of  demarcation  between  the  innermost  and 
the  muscular  layer. 

The  tunica  muSCUlaris  or  media  consists  of  smooth  or  unstriped 
muscular  fibre  with  oval  or  strap-shaped  nuclei.  Such  fibres  being 
ari'anged  transversely  to  the  long  axis  of  the  vessel,  or,  rather,  coiling 
spirally  around  it,  appear  at  right  angles  to  the  longitudinally-disjtosed 
nuclei  of  the  intima.  Where  this  tunic  is  Avell  developed,  a  longitudinal 
section  of  the  vessel  will  often  show  these  muscle  fibres  arranged  in 
series  along  the  margin  of  the  tube,  their  nucleus,  also  divided 
transversely,  giving  them  the  aspect  of  round  nucleated  cells. 
The  limiting  wall   externally  is  also  often  thrown  into   slight  wavy 


/b  THE    CEREBRAL    CORTEX. 

outline  from  the  projection  of  these  muscular  fibres.  In  transverse 
sections  of  the  smaller  arteries  one  or  two  such  muscle  cells  surround 
the  open  lumen.  The  muscular  element  does  not  enter  largely  into 
the  constitution  of  the  cortical  bloodvessels.  These  vessels,  like  those 
of  the  cranial  cavity  generally,  as  well  as  those  of  the  vertebral  canal, 
have  much  thinner  tunics  than  vessels  of  corresponding  calibre  else- 
where from  this  poverty  in  muscular  elements  and  adventitial  tunic 
(^Sharpeij). 

The  tunica  adventitia,  which  in  the  larger  arteries  is  a  connective 
sheath  directly  continuous  with  the  pia  mater  {intima  pia),  becomes  in 
the  smaller  vessels  an  extremely  delicate  membranous  investment, 
faintly  striated  or  structureless,  upon  which  are  found  connective 
corpuscles,  the  nuclei  of  which  ai-e  round  or  somewhat  oval,  A 
membranous  nucleated  tunica  adventitia,  similar  to  the  above,  can  be 
readily  observed  in  larger  capillaries  of  the  hyaloid  membrane  of  the 
frog  (^Eberih*).  The  corpuscles  in  this  adventitial  sheath  form  a  very 
delicate  ^protoplasmic  structure,  of  fusiform  or  stellate  outline,  shrink- 
ing notably  with  hardening  reagents  and  desiccation  of  fresh  brain,  so 
as  to  bring  their  nucleus  much  more  prominently  into  view;  in  fact, 
mounted  specimens  usually  show  the  nuclei  only  along  the  course  of 
the  adventitial  coat.  As  we  shall  see  later  on,  these  nuclei  are  prone 
to  exti'eme  degrees  of  proliferation.  Closely  applied  to  the  tunica 
media,  as  a  rule,  this  adventitial  sheath  is  in  certain  conditions  widely 
separated  from  the  vessel's  wall  in  ampullar  dilatations,  and  at  all 
times  leaves  a  space  between  it  and  the  middle  coat  in  the  angle 
formed  by  the  bifurcation  of  the  vessel.  The  latter,  with  its  sheath, 
traverses  channels  in  the  cortical  substance  which  form  a  wall  limiting 
the  distention  of  the  vessel.  This  limiting  channel  has  no  definite 
endothelial  lining,  so  fixr  as  can  be  discovered  by  the  silver  treatment  ; 
it  is  termed  the  pePivaSCUlaP  Channel  of  His,  and  is  continuous  with 
the  epicerebral  space  between  the  intima  pia  and  the  outer  surface 
of  the  cortex.  Traversing  this  perivascular  space  ai'e  numerous  delicate 
fibrillar  processes,  which,  arising  from  stellate  cells  in  the  substance  of 
the  cortex,  thus  form  connections  with  the  adventitial  sheath  of  the 
artery. 

(2)  The  Capillaries. — These  channels  of  intercommunication  be- 
tween artery  and  vein  are  of  extremely  fine  calibre  in  the  cortex. 
Taking  the  capillaries  of  all  regions,  excepting  the  enormous  capillaries 
of  marrow,  we  may  state  their  average  dimensions  as  between  7  /U.  and 
10  /x,  i.e.,  Avhen  full  of  blood.  The  capillaries  of  the  cortex,  however, 
are  often  not  over  4  ^u.  in  diameter  {j^.?-jjj  inch),  and  are  therefore  of  less 

*  See  Strieker's  Human  and  Comparative  Histolcgy,  vol.  i,  p.  2S7,  fig.  53. 


THE    CAPILLARIES    AND    VEINS    OP    CORTEX.  i7 

calibre  than  the  red  blood-corpuscle.  We  must  allow  for  possible 
shrinking  of  the  vessel  by  emptying  its  channel,  as  well  as  for  the 
constricting  effects  of  reagents,  and  can  scarcely  conclude  that  even 
these  minute  ramifications  do  not  permit  the  passage  of  the  red  blood- 
corpuscle. 

The  only  constituents  of  the  arterial  tunics,  which  enter  into  the 
structure  of  the  cajjillaiy,  are  the  endothelial  layer  or  Intlma  and 
the  adventitial  investment.  In  fact,  the  transition  from  the 
smallest  artery  into  the  larger  capillary  is  indicated  by  the  disappear- 
ance of  the  muscular  fibi-e  cell,  and  the  continuation  of  the  channel  as 
an  apparently  homogeneous  tubular  membrane,  with  oval  nuclei  along 
its  course,  and  here  and  there  niicleated  connective  cells  as  the  sole 
representative  of  the  adventitial  sheath.  The  intima,  which  is  a  direct 
continuation  of  the  endothelial  lining  of  the  arteries  and  by  many 
believed  to  be  the  only  constituent  of  the  capillary,  resembles  that 
lining  in  every  particular  save  the  number  and  form  of  its  squamous 
cells.  These  are  not  only  fewer,  being  often  reduced  to  two  in  a 
transverse  view  of  the  vessel  or  its  lumen ;  but,  instead  of  being 
polygonal,  are  more  often  elongated  into  fusiform  plates.  These 
capillaries  form  good  subjects  for  the  study  of  this  endothelial  tube 
after  the  action  of  silver  nitrate.  The  darkened  cement  substance 
then  displays  not  only  the  outline  of  the  endothelial  plates,  but  various 
sized  slits  and  darkened  areas  termed  stig'mata  and  stomata,  and 
believed  by  some  to  indicate  orifices  through  which  the  colourless 
corpuscles  migrate. 

In  the  smaller  capillai'ies  the  delicacy  of  the  structure  is  such  that  it 
is  at  first  often  overlooked  until  its  course  is  noticed,  mapped  out  by 
short,  narrow,  spindle-shaped  nuclei,  arranged  alternately  at  regular 
distances  on  the  opposite  sides  of  the  vesseh  In  the  same  direction 
also  will  be  found  rounded  nuclei,  staining  readily  with  aniline  blue- 
black,  sometimes  aggregated  into  groups  or  arranged  in  linear  series 
at  very  irregular  intervals  along  the  vessel.  These  are  the  deriva- 
tives of  the  adventitial  sheath,  and  are  therefore  always  external 
to  and  placed  upon  the  fusiform  nuclei.  They  are  often  the  best 
guide  to  the  direction  of  the  capillary  loops  around  the  nerve  cell 
(Plate  V.) 

(3)  The  Veins. — The  venous  channels  of  the  cortex  call  but  for 
short  notice  at  our  hands,  since  they  reproduce  with  certain  modifica- 
tions the  structures  which  enter  into  the  formation  of  the  arterial 
tunics.  It  will  suffice  here  to  show  how  they  difier  from  the  arteries, 
and  to  point  out  the  distinctive  characteristics  of  these  tlirec  divisions 
of  the  vascular  supply — artery,  vein,  and  capillary. 

The   veins   consist,  then,  of  but  three  tunics — the   Intima,    Media, 


78  THE    CEREBRAL    CORTEX. 

and  Atlventitia.  The  tunica  intima  is  similar  to  that  of  the  artery  ; 
but  the  emlotlielial  plates  are  shorter  and  broader,  and  the  nuclei 
rounded  and  fewer  in  numbers.  The  media  contains  no  smooth 
muscle  fibre  cells,  but  consists  exclusively  of  connective  tissue,  whilst 
the  elastic  element  (always  less  developed  in  veins  tlian  in  arteries) 
is  wholly  absent  in  the  small  veins  of  the  cortex.  The  adventitia 
repi'odiices  in  all  respects  what  has  been  already  described  as  consti- 
tuting this  coat  in  arteries. 

Thus  we  see  that  the  veins  may  be  distinguished  from  the  arteries 
by  the  greater  laxity  of  their  tissue — the  absence  of  the  muscular  and 
elastic  element  leading  to  a  wider  lumen;  moreover,  the  thin  media, 
due  to  the  absence  of  muscle  cells,  results  in  a  very  ihin-ioallecl  vessel; 
in  larger  vessels  the  adventitia  also  is  a  more  prominent  feature  than 
the  corresponding  coat  in  arteries. 

The  capillary,  on  the  other  hand,  commences  where  the  middle  coat 
terminates ;  but  to  its  minutest  ramifications  we  still  find  elements 
of  the  adventitia  around  its  delicate  nucleated  wall.  This  certain 
authorities  deny,  but  repeated  examination  leads  us  fully  to  endorse 
this  view,  also  adopted  by  Ebei'th,  whose  views  are  so  much  to  the 
l^oiut  that  we  quote  them  here  : — 

"  Between  the  capillaries  of  the  lij'aloid  of  the  Froc;,  isolated  stellate  cells  occur, 
with  round  nuclei  and  delicate  protoplasm,  branching  off  into  many  processes, 
Avhich  often  anastomose  with  the  processes  of  the  cells  of  the  tunica  adventitia. 
Towards  the  small  arteries  and  veins,  the  pericapillary  plexus  becomes  constantly 
closer,  and  soon  in  its  stead  there  appears  a  delicate  transversely  folded  and 
nucleated  membrane,  which  is  sometimes  elevated  in  the  form  of  small  vesicles. 
.  .  .  A  similar  nucleated  membrane  forms  the  outermost  covering  of  the  larger - 
sized  capillaries,  and  of  the  arteries  and  veins  of  the  brain,  spinal  cord,  and  retina 
of  man. "  * 

.  (c.)  The  Neurog-lia  or  Connective  Basis.— The  more  generally 

accepted  fuuetious  of  the  neuroglia  matrix  would  i-ender  structural 
differentiation  of  tliis  non-nervous  constituent  highly  probable  iu 
different  regions  of  the  cerebro-spinal  system.  This,  we  find,  accords 
with  actual  fact ;  for,  as  a  supporting,  as  well  as  embedding  and 
jjrotecLive  material,  the  requirements  demanded  will  differ  widely  ia 
the  white  medulhited  structures  from  those  of  the  grey  centres  ;  whilst 
individual  sections  of  these  territories  will  also  differ  in  the  special 
qualities  of  this  matrix  requisite.  Thus,  the  large  closely-approximated 
medulhited  filtres  of  the  Spinal  Cord  will  be  found  to  possess  a  strong 
binding    material    in    the    form    of    large-sized    nucleated    cells,    with 

*"Eberth  on  the  Minute  Anatomy  of  the  Capillaries,"  Strieker's  Histology, 
vol.  i.,  p.  2SG. 


THE    NEUROGLIA    MATRIX.  79 

numerous  lengthened  ramifying  processes,  together  with  a  plexus  of 
fine  fibrils  (probably  elastic  fibre — Gerlach) ;  whilst  a  structureless  or 
very  finely  granular  material  is  found  here  but  sparingly.  Still  neai-er 
the  jieriphery  of  the  cord,  this  supporting  structure  becomes  a  veritable 
fibi'illar  connective  sheatli  of  great  strength,  with  trabeculae  of  like 
constitution  passing  inwards  to  the  cord.  In  the  central  grey  matter 
of  the  cord,  however,  the  finely  granular  or  molecular  basis-substance 
predominates,  as  most  essential  for  the  protection  of  the  extremely 
delicate  nerve  fibres  present  in  this  region.  Farther  up  in  the 
medulla  of  the  brain,  as  in  the  neighbourhood  bordering  upon  the 
grey  cortex,  the  large  bundles  of  medullated  fibre  again  demand  a 
predominance  of  the  connective  fibre  element,  so  that  here  we  meet 
with  numerous  though  delicate  ramifying  cells.  Wherever  the  medul- 
lated fibre  reappears,  there  we  find  the  association  of  these  branching 
cells,  and  thus  they  are  seen  along  the  outermost  or  periphei-al  layer 
of  the  cortex  as  a  normal  element.  In  the  grey  matter  of  the  cortex, 
however,  the  delicate  nerve-cell  and  fibre  network  appears  largely  to 
dispense  with  this  modification  of  the  connective  tissue,  and  we  find 
a  structureless  matrix  vastly  preponderating  over  the  cell  and  nuclear 
elements  of  the  neui-oglia. 

A  still  further  modification  of  the  neuroglia  element  is  found  on  the 
free  surfaces  of  the  cortex  immediately  beneath  the  pia,  where  the 
branching  cell  before  described  fulfils  the  function  of  a  flattened 
epithelial  investment,  whilst  the  surfaces  not  exposed  to  pressure,  as 
the  central  canal  of  the  cord,  show  us  the  element  as  a  columnar 
epithelium. 

Thus,  generally,  we  may  afiirm  that,  when  dealing  with  nerve  cells 
and  their  delicate  extensions,  the  supporting  material  will  be  chiefly 
the  structureless  or  finely  moleCUlaP  basiS-SUbstance  ;  whilst  as 
we  approach  the  medullated  tracts,  we  shall  find  that  the  connective 
cell  and  fibre  networks  increase  at  the  expense  of  the  former. 

The  elements  of  the  neuroglia  are  usually  described  as  nucleated  cells 
and  free  nuclei  imbedded  in  a  structureless,  or,  according  to  some,  finely 
fibrillated  matrix,  and  to  this  view  the  appearance  of  chrome-hardened 
preparations  certainly  lends  support.  The  less  we  subject  our  sections 
to  reagents,  and  the  more  recent  the  section  examined,  however,  the 
more  evident  it  becomes  that  the  supposed  free  nuclei  are  invested  by 
protoplasm,  and,  in  fact,  are  likewise  nucleated  cells.  These  two  cell 
elements  diff'er  much  as  regards  their  relationships  and  also  their 
dimensions. 

(1)  The  smaller  of  the  two  hinds  of  cell  vary^from  G  /x  to  9  ,a  in 
diameter;  have  a  spheroidal  nucleus,  surrounded  by  an  extremely 
delicate    protoplasmic    investment,    which,    as    before    intimated,    is 


80  TUE   CERKCRAL   CORTEX. 

shrunken,  often  beyond  recognition,  in  hardened  specimens.  The 
nucleus  is,  proportionately  to  the  cell  itself,  very  large,  and  invariably 
stains  of  an  intense  de-pth  of  colour  with  aniline  blue-Vjlack.  These 
elements  appear  disposed  in  thi-ee  definite  situations — (1)  irregularly 
in  the  neuroglia  framework  ;  (2)  in  regular  series  around  the  nerve 
cells ;  (3)  in  more  or  less  regular  succession  along  the  course  of  the 
blood-vessels  (capillary  and  arteriole). 

(2)  I'lie  larger  cellular  elements  of  the  neuroglia  are  usually  13  im  in 
diameter,  and  supplied  with  a  relatively  larger  mass  of  protoplasm  as 
compared  with  the  nucleus.  They  are  distinguished  from  the  former 
not  alone  by  this  gi-eater  size  and  the  preponderance  of  cell  over 
nucleus ;  but  also  by  their  frequent  flask-like  configuration,  as  seen 
in  situ,  and  the  presence  of  a  very  faintly-stained  nucleus,  or  even 
sometimes  two  or  three  nuclei,  observed  within  them.  If  these 
elements  are  teazed  out  from  the  surrounding  matrix,  they  are  seen 
to  possess  numerous  extremely  delicate  radiating  processes ;  not  only 
the  nucleus,  but  the  cell  and  its  extensions  are  likewise  tinted  by  the 
aniline  dye ;  not  uniformly,  howevei',  for  the  nucleus  is  always  of  a 
slightly  deeper  tint,  but  neither  cell  nucleus  nor  processes  betray 
anything  like  the  vigour  of  staining  shown  by  the  former  element 
described.  The  nerve  cell,  its  processes,  and  the  enclosed  nucleus 
had,  as  we  said,  a  si^ecial  affinity  for  this  staining  reagent,  a  fact 
which  indicates  very  conclusively  the  non-nervous  character  of  these 
lai'ger  elements  of  the  neuroglia.  In  healthy  brain,  at  least  in  the 
human  subject,  we  find  these  elements  chiefly  in  the  outermost  layer 
of  the  cortex  and  the  central  cone  of  the  medulla,  but  their  delicacy, 
tenuity  of  branches,  very  faint  staining,  and  poor  difl'erentiation  ai'C  not 
favoui'able  to  their  immediate  detection.  In  certain  morbid  conditions 
of  the  cortex,  as  we  shall  see  later  on,  these  elements  become  a  most 
notable  and  important  feature,  xmdergoing  excessive  proliferation,  and 
betraying  their  morbid  activity  by  the  intensity  of  colouring  which 
they  acquire.  This  study  of  the  constituent  histological  elements  of 
the  cortex  prepares  us  for  the  consideration  of  the  lymphatic  system 
of  the  brain,  and  the  ultimate  relationships  of  IS'erve  cell  to  the 
Blood  and  Lymph  channels. 

{d.)  Lymphatic  System  of  the  Brain. — To  Obersteiuer  is  due 

the  credit  of  first  definitely  indicating  the  existence  and  relationships 
of  these  lymph  channels.*  Their  existence  since  then  has  been  re- 
peatedly denied,  but  the  evidence  hitherto  brought  forward  against 
Obersteiner's  views  is  most  inconclusive  in  all  respects,  and  in  most 

*"Uber  einige  Lymphraiime  im  Gehirne"  [Silsb.  d.  K.  Akad.  d,  Wissensch., 
Jan.  Heft,  1870). 


LYMPHATIC    SYSTEM    OF    CORTEX.  81 

cases  appai'ently  based  upon  incomplete  methods  of  examination. 
This  is  not  tlie  place  to  enter  on  debateable  ground ;  but  we  are 
compelled,  owing  to  the  supi"eme  importance  of  the  subject  as  affecting 
the  physiology  and  ^lathology  of  the  brain,  to  state  the  results  of  our 
own  investigations,  which  were  made  the  subject  of  a  special  memoir 
in  1877.* 

All  hardened  sections  of  brain  exhibit  along  the  course  of  their 
blood-vessels  a  distinct  and  more  or  less  wide  interval  between  the 
vascular  walls  and  the  brain-substance ;  in  fact,  the  brain-cortex  is 
channelled  throughout,  in  such  a  manner,  that  the  vessels  when  con- 
ti'acted  are  enclosed  within  a  channel  of  much  greater  calibre.  The 
disparity  betwixt  the  diameter  of  vessel  and  bi'ain-channel  will  be 
affected  undoubtedly  by  corrugating  reagents ;  and  hence,  we  never 
fail  to  find  these  channels  disproportionately  lai-ge  in  brain  which  has 
been  subject  to  extremes  of  hardening  by  chromic  acid,  (fee;  but 
recession  of  the  brain-substance  may  occur  from  many  other  causes 
acting  during  life  —  notably  extreme  atrophic  degeneration ;  and 
then,  in  like  manner,  such  channels  will  appear  inordinately  large, 
however  skilfully  the  brain  be  prepared.  These  channels  are  known 
by  the  name  of  the  perivascular  Channels  of  the  brain — the  peri- 
vascular channels  of  His  :  these  are  not  the  lynij)h  channels  proper,  as 
several  writers  seem  to  have  supposed,  but  are  simple  channels  in  the 
brain-substance,  devoid  of  an  endothelial  lining,  and  communicating 
freely  with  the  space  between  the  investing  pia  mater  and  surface  of 
the  cortex,  the  eplcerebral  space.  The  adventitial  sheath  of  the 
blood-vessels  becomes  closely  appressed  to  this  limiting  channel,  and 
its  (adventitial)  nuclei  often  thus  give  it  the  appearance  of  being 
lined  by  endothelial  cells.  This,  however,  is  not  the  case,  as  re- 
peated investigations  by  silver  staining  have  shown.  The  student 
cannot  too  persistently  bear  in  mind  the  fact  that  in  these  channels 
he  deals  purely  with  what  seems  equivalent  to  an  involution  of  the 
naked  surface  of  tlie  brain,  and  yet  the  epithelial  elements  of  the  epi- 
cerebral  surface  are  not  continuous  along  this  tubular  channel. 

In  the  next  place  we  find,  luider  precisely  similar  conditions  to 
those  above  enumerated,  a  wide  space  around  the  larger  nerve  cells ; 
the  brain-substance,  as  it  were,  seems  to  have  receded  from  the  cell,  so 
that  it  is  enclosed  within  a  circular,  oval,  or  pyriform  space.  These 
spaces  we  will  designate  the  pericellular  saCS.  Genuine  sacs,  and  not 
mere  artificial  gaps  in  the  brain-substance,  they  undoubtedly  are,  as  is 
abundantly    proved   by   cai-eful    examination.       To    exhibit   the   true 


*  "The  Relationships  of  the  Nerve  Cells  of  the  Cortex  to  the  Lymphatic  System 
of  the  Brain,"  Proc.  Roy.  Soc,  No.  IS'2,  1877. 

6 


S'2  THE    CEREDHAL    CORTEX. 

relationships  of  these  perivascidar  channels  and  pericellular  sacs,  let 
us  revert  to  the  smaller  cellular  element  described  in  the  neuroglia 
(p.  80),  It  was  stated  that  beyond  the  scattered  elements  in  the  basis 
substance  of  neuroglia,  these  cells  were  arranged  in  two  other  direc- 
tions.    Let  us  particularise  : — 

(1)  The  nucleated  cells  along  the  arterioles  belong  to  the  adventitial 
tunic,  and  map  out  its  course  very  accurately ;  occasionally  closely 
applied  to  the  perivascular  channel,  as  before  stated,  or  separated  as 
irregular  ampullse  from  the  vessel  itself,  this  investment  more 
frequently  lies  directly  upon  the  media,  and  affords  one  (but  an 
equivocal)  evidence  of  the  existence  of  a  lymph  channel  surrounding 
the  vessel.  That  a  complete  tubular  membrane  exists  for  a  certain 
distance  along  the  smaller  arterioles,  is  demonstrable ;  that  it  is 
continuous,  as  a  membrane,  further  on  to  the  arterio-capillary  plexuses, 
is  more  than  dubious.  It  is  certain,  however,  that  its  representative 
cells  are  to  be  found  sui'rounding  these  minute  channels  to  their 
ultimate  ramifications ;  and  thus  the  perivascular  hjmfli  space  of  the 
adventitia  becomes  continuous  in  these  districts  with  the  general 
perivascular  channels  and  sacs  around  the  nerve  cells. 

(2)  The  nucleated  cells  found  in  connection  with  the  nerve  cells  in 
certain  states  not  only  acciimulate  upon  the  nerve  cell  itself,  but 
follow  closely  the  outline  of  the  cavity,  or  properly  speaking,  the  sac 
in  which  the  nerve  cell  lies.  Many  pericellular  sacs  will  show  a 
complete  series  of  such  nucleated  cells  around  it,  still  more  frequently 
will  they  follow  out  a  segment  only  of  its  circular  outline;  occasionally 
none  may  be  seen — an  exception  due  probably  to  displacement  during 
section-cutting  or  further  manipulation.  Upon  closer  observation, 
however,  it  becomes  apparent  that  in  the  immediate  neighbourhood  of 
every  large  nerve  cell  there  is  a  minute  arteriole  or  capillary,  not 
indicated  so  often  by  a  well-differentiated  contour  (for  these  minute 
vessels  are  usually  most  difficult  to  follow),  as  by  the  direction  of  its 
nucleated  cells.  Thus,  the  fusiform  nuclei  of  the  intima,  alternately 
placed  on  opposite  sides  of  the  capillary,  will  lead  to  the  discovery  of 
the  outline  of  the  vessel  faintly  indicated  in  a  graceful  curve  or  spiral 
in  close  approximation  to  the  nerve  cell;  but  the  presence  of  the  deep- 
stained  nuclei  of  the  adventitial  cells  taking  the  saine  course,  plainly 
indicates  the  direction  of  these  ultimate  nutrient  channels.  It  is 
these  adventitial  elements  which  give  us  the  clue  to  tracing  the 
obscurely  marked  capillary,  and  when  this  is  followed  out,  the  eye 
becomes  accustomed  to  trace  without  any  difficulty  the  vascular  loop 
around  the  nerve  cell. 

Around  a  segment  of  the  pericellular  sac,  mapped  out  by  adven- 
titial elements,  we  then  see  a  delicate  tubular  loop,  evidently  con- 


PERIVASCULAR    CHANNELS  —  PERICELLULAR    SACS.  83 

tinuous  with  the  neighbouring  arteriole,  and  to  the  sides  of  which 
the  pericellular  sac  appears  to  be  attached,  the  nerve  cell  itself 
being,  as  it  were,  suspended  within  the  latter.  It  would  appear 
as  if  the  geiiei-al  perivascular  channels  at  their  ultimate  ramifica- 
tions around  the  arterio-capillary  plexuses  were  enlarged  here  and 
there  laterally  along  the  vessel  by  the  growth  of  an  element  included 
within  it  which  becomes  the  nerve  cell,  and  which  does  not  come  in 
contact  with  the  neuroglia  mati'ix  except  through  the  medium  of  its 
processes,  which,  passing  through  the  pericellular  sac,  permeate  the 
neuroglia  in  every  direction.  It  would  appear  also  from  examina- 
tion of  specially  prepared  sections,  that  the  adventitial  elements  are 
not  entirely  limited  to  the  vascular  loop,  but  may  line  the  interior  of 
these  sacs — not  as  a  regularly  applied  endothelial  layer,  but  as  loosely 
.distributed  and  branching  cells.  In  like  manner,  similar  cells  may  be 
found  free  within  the  cavity  of  the  sac  between  its  wall  and  the  nerve 
cell,  resembling  in  all  particulars  lymph  corpuscles. 

Beyond  the  system  of  perivascular  channels,  adventitial  lymph 
space,  and  pericellular  sac,  we  have  a  lymph-COnnective  system 
which  plays  an  important  role  in  the  pathology  of  the  brain.  This 
system  is  constituted  by  the  larger  connective  element  referred  to 
above — the  delicate  branching  masses  of  protoplasm  supplied  usually 
with  one,  sometimes  with  two,  or  even  three  large  nuclei.  These 
elements,  when  more  closely  examined,  are  found  to  have  a  definite 
and  constant  relationship  to  the  cortical  blood-vessels  ;  and  are  always 
discovered  in  larger  numbers  in  their  immediate  neighbourhood, 
external  to  the  perivascular  channels.  The  latter  present  where  they 
are  well  seen,  and  the  adventitial  sheath  is  appressed  to  the  vessel's 
side,  a  series  of  delicate  processes,  which,  traversing  the  channel,  look 
like  fibres  extending  from  the  adventitia  into  the  brain-substance. 

AVhat  are  these  fibrous  prolongations  ?  Careful  examination  of  one 
of  the  large  neuroglia  elements  reveals  the  fact  that  they  throw  ofi"  two 
sets  of  processes — (1)  an  enormous  number  of  extremely  delicate  fibres, 
which  spread  into  the  intervascular  area  around,  and  (2)  a  mioch  thicket', 
coarser  process,  which,  often  after  a  tortuous  course,  ends  in  the 
adventitial  sheath  of  the  blood-vessel.  In  crossing  the  perivascular  sac, 
these  processes  give  rise  to  the  fibres  just  described  as  extending 
between  adventitia  and  brain-substance. 

It  is  in  certain  morbid  developments  of  these  cells  that  we  can  the 
more  readily  distinguish  their  real  relationships.  We  find  that 
the  stouter  process,  which  we  may  provisionally  term  the  vasCUlaP, 
terminates  in  a  nucleated  mass  of  protoplasm  on  the  sheath  itself, 
corresponding  to  one  of  the  perivascular  or,  more  properly,  adventitial 
cells.     In  morbid  states,  as  we  shall  see,  this  terminal  protoplasm  of 


84  THE    CEREBRAL    CORTEX. 

the  vascular  process  "becomes  spider-like,  in  its  turn  throwing  off 
numerous  branches,  which  embrace  the  vessel's  -wall.  In  the  healthy- 
state,  it  is  most  difficult  to  trace  the  vascular  branch ;  but  that  this 
can  be  done  by  proper  methods,  we  have  frequently  satisfied  ourselves. 
The  branched  cells  which  Ave  have  now  described  have  often  been 
recognised  in  their  morbid  modifications,  and  variously  interpreted. 
Their  representatives  in  healthy  brain  were  first  described  by  Deiters,* 
and  subsequently  by  Ball  and  Golgi ;  but  we  do  not  think  their  true 
significance  has  been  recognised  either  as  normal  or  pathological 
elements  of  the  central  nervous  system.  "We  incline  to  regard  these  ele- 
ments as  comprising  the  distal  extension  of  a  lymphatic  system, 

in  fact  as  a  lymph-COnnective  system  permeating  the  neuroglia 
in  the  intervascular  area.  The  individual  elements  are  excessively 
delicate  and  pellucid,  their  protoplasm  appearing  almost  of  fluid  con- 
sistence, and  the  vascular  process  invariably  establishing  its  connection 
with  the  lymph  sheath  of  a  blood-vessel.  In  whatever  manner  these 
spider  cells  efi"ect  the  reabsorption  and  distribution  of  tlie  effete 
matei'ial  and  surplus  plasma — whether  by  direct  assimilation  into  their 
own  structure,  and  its  removal  by  currents  within  the  protoplasm  of 
the  cell  and  its  processes,  or  by  means  of  a  true  canalicular  system 
terminating  in  the  lymph  sheath — it  is  an  undoubted  fact  that  any 
arrest  to  the  escape  of  perivascular  lymph  from  the  cortex  is  imme- 
diately followed  by  a  morbid  development  and  hypertrophic  condition 
of  this  system  of  spideP  Cells,  as  we  shall  for  the  future  call  these- 
elements  of  the  "lymph-connective  system."  Meynert  long  since  drew 
attention  to  their  freqiient  pi'esence  as  associated  with  congestion 
and  degeneration  of  the  lymphatic  glands  of  the  head  and  neck,  and 
we  haA^e  assured  ourselves  of  the  frequent  association  of  this  morbid 
development  in  tuberculosis,  and  in  several  affections  of  the  cortex  and 
its  membranes  which  lead  to  obstruction  of  the  perivascular  lymph 
channels.t     The  morbid  changes  undergone  by  this  lymph-connective 

*  Hence  they  are  often  named  after  him — Deiters'  cells. — Untersiichungcn  iiber 
Gehirn  und  E'uckenviark  der  Menschen  und  dcr  Suitrjcthlere,  1S65. 

+  We  have  elsewhere  alluded  to  the  comparative  significance  of  these  elements  as 
follows: — "In  man  they  appear  in  scanty  numbers;  in  the  Barbary  ape,  they 
become  more  frequent ;  in  the  cat  and  ocelot,  they  are  still  more  abundant ;  in  the 
pig  and  sheep  so  profusely  scattered  are  they  that  they  form  a  most  characteristic 
stratum  immediately  below  the  pia  mater,  and  the  meshwork  formed  by  their 
fibres  is  dense  and  coarse,  binding  the  blood-vessels  to  the  cortex  and  rendering  the 
pia  mater  strongly  adherent.  We  find  these  corpuscles  in  human  brain  which 
has  undergone  senile  degeneration — in  other  diseases  attended  by  reduction  in 
functional  activity,  and  in  vascular  affections  resulting  in  retrogressive  changes 
and  a  reversion  to  a  low  type  of  structure." — "  Comxiarative  Structure  of  the  Corte.x: 
Cerebri."     Trans.  Eo>jal  Soc,  part  i.,  ISSO. 


SPIDER    CELLS    OF    LVMPU-CONNECTIVE    SYSTEM.  §5 

system  and  the  effects  of  its  moi'bid  activity  will  be  more  fully  dealt 
with  when  ti'cating  of  the  pathology  of  the  cortex.  For  the  present 
we  shall  summarise  the  above  statements  as  follows  : — The  lymphatic 
S3'stem  of  the  brain  consists — 

(1)  In  the  fii'st  place,  of  a  distensible  lymphatic  sheath,  loosely  applied 
around  the  arterioles  and  venules,  containing  numerous  nucleated 
cells  in  its  texture — the  adventitial  lymph  sheath,  the  whole  being 
included  within  a  non-distensible  channel  of  the  brain-substance,  devoid 
of  endothelial  lining — the  perivascicla7'  channel  of  II is. 

(2)  In  the  second  place,  of  a  continuation  of  the  cellular  elements  of 
this  sheath,  loosely  applied  to  the  arterio-capillapy  plexuSGS,  still 
contained  within  a  perivascular  channel,  which  now  exhibit  along  the 
capillary  loop  sac-like  dilatations — the  pericellular  sacs,  within  which 
the  nerve  cell  lies,  surrounded  by  plasma. 

(3)  Lastly,  of  a  system  of  plasmatic  cells  with  numerous  prolon- 
gations, which  are  always  in  intimate  connection  with  the  adventitial 
lymph  sheath,  and  which  drain  the  areas  between  the  vascular 
bi-anches — these  we  have  termed  the  lymph-connective  elements. 

.  If  we  take  a  comprehensive  view  of  the  whole  system — the  channelled 
vascular  tracts,  the  saccular  ampullse  along  the  capillary  tube,  the 
caualicular-like  formation  of  the  lymph-connective  elements,  all  em- 
bedded in  a  homogeneous  matrix  of  neuroglia — we  cannot  but  be 
struck  by  the  sponge-liJce  arrangement  of  the  cortex,  and  the  facilities 
so  aiforded  for  the  free  circulation  of  plasma  throughout  its  most 
intimate  regions. 


CORTICAL   LAMINATION. 

Having  familarised  himself  with  the  individual  histological  elements 
of  the  cortex — the  nerve  cells,  blood-vascular  and  lymph-vascular 
systems,  and  the  neuroglia  framework — it  becomes  the  student's  duty 
to  examine  their  general  arrangements  and  the  local  deviations  to  be 
observed. 

A  vertical  section  of  fresh  cortex  of  human  brain  reveals  to  the 
naked  eye  a  distinctly  laminated  aspect,  the  various  laminse  of  which 
are  more  or  less  clearly  marked  out  by  difference  in  colour,  the  outer 
being  usually  of  a  pale  translucent  grey,  and  the  deeper  of  alternating 
pale  and  dark  grey  layers,  more  opaque  in  aspect,  and  in  certain 
regions  exhibiting  a  sharply  defined  white  streak.  The  outer  trans- 
lucent layer  has  superimposed  on  it  a  delicate  white  stratum,  scarcely 
appreciable  on  the  convexity  of  the  hemisphere,  but  well  marked 
in    the    convolutions   boi'dering   upon  the    cor^tus    callosum,   and  the 


8G  LAMINATION  OF  CEREBRAL  CORTEX. 

convolution  of  the  hippocampus,  at  tlie  Laso,  where  its  peculiar 
aspect  has  gained  for  it  the  name  of  the  reticulated  White  SUb- 
Stance.  As  we  shall  see  latei-  on,  this  is  a  superficial  layer  of  white 
medullated  fibre  running  parallel  to  the  surface  of  the  convolution ; 
whilst  the  paler  intersecting  streaks  deeper  down  in  the  cortex  are 
similar  systems  of  arciform  intracortical  fibres  intervening  between 
layers  of  grey  substance.  The  deeper  layers  owe  their  opacity  to  the 
relatively  large  proportion  of  medullated  fibres  passing  through  them  ; 
the  upper  layers  are  translucent  from  the  preponderance  of  the 
neuroglia  element  and  fine  protoplasmic  processes  of  the  nerve 
cells ;  the  warmer  grey  tints  are  due  not  only  to  large  niimbers 
of  pigmented  nerve  cells,  but  chiefly  to  the  amount  of  blood  in  the 
vessels  of  the  layer. 

As  might  be  supposed  from  the  above,  the  distinctness  of  lamination 
not  only  varies  with  the  local  peculiarities  of  structure,  but  with 
morbid  states  of  the  cortex  and  with  the  full  or  empty  state  of  its 
vessels.  Probably  the  best  introduction  the  student  can  have  to  the 
study  of  the  human  cortex  is  to  commence  first  with  the  brain  of 
one  of  the  lower  mammals,  choosing  one  of  the  smooth  non-con- 
voluted brains,  as  of  the  rat  or  rabbit,  ere  he  attempts  the  more 
complicated  brain  of  those  animals  which  exhibit  a  convoluted 
surface.  He  thereby  learns  to  appreciate  the  great  diversity  of 
lamination  which  may  exist  in  so  small  an  organ  as  the  brain  of  the 
rodent,  as  also  the  abrupt  transition  from  one  type  of  cortex  to  that  of 
another  wholly  different  from  it,  and  lastly  he  becomes  familiar  with 
types  of  lamination  which  are  strictly  reproduced  in  higher  forms  up 
to  the  brain  of  man. 

Figs.  1-3  in  Plate  i.  represent  the  brain  of  the  rabbit  seen  from  its 
upper,  lower,  and  median  aspect,  of  somewhat  pyriform  contour  below 
at  the  base,  and  triangular  above ;  its  frontal  pole  is  much  attenuated, 
and  rests  upon  the  olfactory  lobe.  On  its  inner  aspect  we  see  two 
very  delicate  furrows  (fig.  1,  A)  which  represent  the  sub-frontal  and 
sub-parietal  segments  of  the  limbic  fissure,  which  is  strongly  marked 
in  the  brains  of  the  pig  and  of  the  sheep  ',  this  ri;dimentary  fissure 
limits  the  upper  limbic  arc  (between  A  and  J)  from  the  extra- 
limbic  or  parietal  mass  of  the  hemisphere  (fig.  3,  Z,  Y). 

If  we  follow  this  upper  limbic  arc  from  before  backwards,  we  find 
that  its  anterior  extremity  is  deep,  and  that  it  gradually  becomes  more 
shallow  towards  the  sub-parietal  furrow;  beyond  this  it  is  hollowed 
out  by  the  prominence  of  the  mesencephalon  and  overhung  by  the 
occipital  pole  (fig.  1,  D),  and  curving  downwards  behind  the  corpus 
callosum,  it  bends  forwards  as  the  gyrus  hippocampi  or  lower  limbic 
arc  (figs.  1,  2,  B). 


CEREBRAL    IIEMISPnERE    OF    THE    RODENT.  8T 

Looked  at  from  the  base,  we  see  the  lower  limhic  arc  separated  from 
the  extra-limbic  mass  by  a  well-defined  fissui'e — the  limbic  fissure, 
which  here  separates  the  lower  limbic  arc  from  the  extra-limbic  mass, 
the  latter  being  still  prominent  and  not  concealed  from  this  aspect,  as 
in  the  rat,  where  the  lower  limbic  arc  extends  farther  outwards. 
Extending  back  from  the  frontal  pole  are  the  olfactory  lobes,  the  outer 
roots  of  which  (or  superficial  olfactory  medulla)  terminate  near  the 
extremity  of  the  gyrus  hippocampi.  These  two  external  olfactory 
roots  enclose  between  them  two  pyriform  grey  areas,  one  on  each  side, 
separated  by  the  middle  line,  bounded  behind  by  the  optic  commis- 
sure— the  optic  nerves  lying  superficial  to  them.  This  grey  area  is 
the  olfactory  field  of  Gratiolet.  Between  the  olfactory  area  and  the 
lower  limbic  arc,  a  vei'y  slight  depression  indicates  the  site  of  a 
rudimentary  Sylvian  fissure. 

Looked  at  from  above,  we  find  the  surface  of  what  Broca  would  call 
the  extra-limbic  portion,  perfectly  smooth,  and  showing  no  indica- 
tions of  rudimentary  furrowing  beyond  a  very  delicate,  shallow,  linear 
depression,  mapping  off  the  sagittal  region  of  the  brain  from  the  parietal 
or  extra-limbic  portion  in  the  posterior  half  of  the  hemispheres.  This 
is  the  representative  of  the  primary  parietal  sulcus,  which,  in  the  Pig, 
Sheep,  and  other  Gyrencephala,  separates  the  sagittal  from  the  Sylvian 
gyri  of  the  parietal  lobe.  In  the  rat  no  such  linear  depression  exists ; 
but,  this  region  bordering  on  the  sagittal  margin  posteriorly,  is  clearly 
ma'pped  out  by  its  distinctly  jmle  aspect  as  compared  with  the  cortex 
external  to  it. 

The  different  regions  which  we  have  now  indicated  are  all  dis- 
ting\iished  by  a  type  of  cortex  peculiar  to  each ;  and  thus  the  upper 
limbic  arc,  the  lower  limbic  arc,  the  olfactory  area,  the  exti'a-limbic  or 
parietal  portion — areas  obviously  differentiated  roughly  from  one  an- 
other by  sulci  or  faint  indications  of  furrowing — all  exhibit  absolutely 
distinct  types  of  cortex.  But  this  difi'erentiation  does  not  stop  here ; 
the  pale  strip  of  cortex  bordering  upon  the  sagittal  margin  in  the  rat, 
although  not  mapped  off  by  a  distinct  furrow,  has  also  its  own  peculiar 
type  of  cortex ;  and  in  the  rabbit,  as  we  have  seen,  this  region  is 
further  differentiated  by  a  linear  furrowing.  Then,  again,  the  lower 
limbic  arc,  if  traced  backwards,  presents  us  beneath  the  occipital  pole 
with  a  further  modification,  which  can  only  be  regarded  as  a  distinct 
type  of  cortex.  If  we  add  to  the  above  the  formation  of  the  cornu 
ammonis  and  of  the  olfactory  bulb,  we  have  presented  to  us  eight 
distinct  types  of  cortex,  not  mere  fanciful  distinctions  based  upon 
trivial  peculiarities ;  but,  in  all  cases,  abrupt  transitions  from  one  kind 
of  cortex  to  another.  This  divergence  in  laminar  type  is  peculiarly 
abrupt  in  these  lower  forms  of  life,  the  demarcation  usually  being 


88  LAMINATION    OF   CEREBRAL   CORTEX. 

sharply  drawn  at  the  furrows  intervening  between  these  regions.  In 
liigher  animals,  and  especially  in  man,  no  such  abrupt  demarcation 
occurs ;  distinct  tPansition  TGg'ions  lie  between  either  territory,  so 
that  the  gradual  passage  from  one  form  of  cortex  to  another  is  a  dis- 
tinctive element  in  the  evolution  of  the  higher  brains  *  (Brain, 
vol.  i.,  page  84).  The  eight  laminar  types  of  cortex  which  are  thus 
distinguishable  in  these  small  mammalian  brains,  we  have  named  as 
follows : — 

(1)  Type  of  the  upper  limbic  arc.  (5)  Modified  olfactory  type. 

(2)  Modified  upper  limbic  tyjie.  (6)  Extra-limbic  type. 

(3)  Outer  olfactory  type.  (7)  Type  of  cornu  ammonis. 

(4)  Inner  olfactory  type.  (8)  Type  of  olfactory  bulb. 

On  the  other  hand,  we  find  that  Meynert  enumerates  but  five  types 
as  follows  : — 

(1)  Common  type.  (.3)  Sylvian  type. 

(2)  Occipital  type.  (4)  Type  of  coi-nu  ammonis. 

(5)  Type  of  olfactory  bulb. 

If  we  turn  to  our  outline  scheme  of  the  rabbit's  brain  (Plate  i.),  we 
shall  find  these  diverse  forms  of  cortex  distributed  in  the  following 
regions : — 

(1)  The  first,  or  the  type  of  the  uppeP  limbic  arC,  occupies  the 
median  cortex  of  the  hemisphere  from  the  frontal  jiole  to  the  end  of 
the  sub-parietal  furrow  (figs.  1-3,  -h )  ;  it  moreover  spreads  beyond 
the  sagittal  margin,  and  embraces  the  pointed  frontal  extremity  of 
the  exti'a-limbic  region  at  the  vertex. 

(2)  The  second,  or  modified  upper  limbic  type,  prevails  also  on 
the  median  cortex  behind  the  above  type,  extending  to  the  occipital 
pole,  but  also  spreading  outwards  over  the  sagittal  border  to  the  upper 
aspect  of  the  hemisphere,  where  it  terminates  abruptly  at  the  parietal 
furrow  (dotted  area). 

(3)  The  third,  or  outer  Olfactory  type,  characterises  the  cortex 
of  the  greater  segment  of  the  lower  limbic  arc  to  its  extremity — the 
gyrus  hippocampi  (figs.  1,  2,  B). 

(4)  The  fourth,  or  inner  olfactory  type,  covers  the  grey  pyriform 

*  In  his  earlier  memoir,  published  in  Strieker's  Human  and  Comjmrative  Ilixlology, 
as  well  as  in  his  later  views  expressed  in  Psycliiatnj,  MejTiert  defines  but  five 
types  of  cortical  lamination  as  distinctive  of  the  brain  in  mammals.  We  find  our- 
selves unable  to  agree  with  Meyuert,  not  only  as  regards  his  enumeration  of  types 
of  lamination,  but  in  some  cases  as  regards  his  description  of  the  specific  characters 
of  individual  tyjies  of  cortex. 


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TYPES    OP    CORTICAL    LAMINATION.  89 

ai'eas  enclosed  witliiii  the  last  mentioned  and  the  outer  root  of  the 
olfactory  bulb  (tig.  2,  dark  area). 

(5)  The  fifth,  or  modified  olfactOPy  type,  occupies  the  posterior 
segment  of  the  lower  limbic  arc,  where  it  sweeps  round  posteriorly  to 
meet  the  upper  limbic  arc.  This  form  of  cortex,  unique  of  its  kind,  is 
also  abruptly  limited  externally  by  the  great  limbic  fissure. 

(G)  The  sixth,  or  extra-limbic  type,  is  peculiar  to  the  whole  of 
the  extra-limbic  or  parietal  portion  of  the  hemisphere,  except  the 
regions  already  described  as  presenting  a  peculiar  lamination.  Thus 
it  occupies  the  whole  of  the  vertex  except  the  portion  internal  to  the 
parietal  furrow,  and  the  pointed  end  of  the  hemisphere  in  front,  whilst 
elsewhere  it  is  strictly  demarcated  from  other  regions  by  the  great 
limbic  fissure. 

(7)  The  seventh,  or  type  Of  the  COPnu  ammonis,  characterising 
the  involuted  free  margin  of  the  cortical  envelope,  is,  of  course,  con- 
cealed from  view  in  these  aspects  of  the  hemisphere. 

(8)  The  eighth,  or  type  Of  the  olfactOPy  bulb,  has  its  distribu- 
tion sufiiciently  indicated  by  its  name  (figs.  1,  2,  F). 

A  brief  description  of  the  peculiarities  of  these  cortical  belts  of  nerve 
cells  will  be  all  that  is  needful  for  our  present  purpose. 

(1)  Upper  Limbic  Type. — The  cortical  lamination  here  referred  to 
is  illustrated  in  Plate  i.     The  area  it  covers  is  presented  in  figs.  1-3,  + . 

It  is  essentially  a  four-laminated  type :  its  first  or  superficial  layer 
being  a  light  grey  belt  of  delicate  neuroglia  matrix,  with  connective 
elements  and  their  fine  prolongations  supporting  the  extremely  delicate 
subdivisions  of  the  apical  px-ocesses  of  nerve  cells  in  the  subjacent 
layers.  iVo  nerve  cells  are  found  in  this  layer,  which  we  term  the 
"peripheral  cortical  zone"  (Plate  i.)  Next  to  this  succeeds  a  layer  of 
small  pyramidal  cells,  which,  down  to  the  confines  of  the  third  layer, 
remain  equable  in  size  throughout ;  in  all  respects  these  elements  bear 
close  resemblance  to  the  upper  half  of  the  third  layer  in  higher 
animals.  They  difi'er  from  the  human  cortex  (1)  in  not,  as  in  the 
latter,  rapidly  increasing  in  size  with  their  depth,  and  (2)  in  following 
immediately  upon  the  peripheral  cortical  zone  with  no  intervening 
belt  of  small  oval  and  angular  cells,  such  as  characterises  the  second 
layer  in  man.  A  few  bifurcate  cells  in  sparse  detached  clumps  occur 
on  the  outermost  confines  of  this  layer,  probably  rudimentary  elements 
of  the  second  layer  of  man.  Beyond  the  layer  of  small  pyramidal  cells, 
is  a  pale  belt  containing  the  largest  cells  of  the  cortex — a  pale  poorly- 
celled  zone  demarcating  them  from  the  superimposed  layer  of  pyra- 
midal cells.  These  elements  are,  however,  distinguished  from  the 
latter  not  alone  by  their  great  size,  but  by  their  distribution  into 
confluent  groups  or  clusters,  which,  as  we  shall  see  later  on,  is  a  special 


90  LAMINATION   OP   CEREBRAL   CORTEX. 

character  of  the  large  nerve  cells  of  the  motor  cortex.  Their  apex  pro- 
cess extends  right  tlirough  the  pyramidal  series  into  the  peri})horal 
zone.  We  cannot  now  stop  to  inquire  into  their  many  striking  features. 
Beneath  these  large  cells  is  a  series  of  fusiform  elements,  similar  in  all 
respects  to  those  found  in  higher  mammals.  This  type  of  cortex, 
thei'efore,  is  constituted  by 

(1)  A  pei'ipheral  cortical  zone.         (3)  Ganglionic  layer. 

(2)  Small  pyramidal  layer.  (4)  Spindle  cell  layer. 

(2)  Modified  Upper  Limbic  Type. — This  form  of  cortex,  like  the 
last,  is  also  a  four-laminated  type.  Near  the  posterior  extremity  of  the 
corpus  callosum  (Plate  iv.,  fig.  1),  the  upper  limbic  arc  exhibits  the  in- 
tercalation of  a  series  of  granule  CCllS  between  the  small  pyramidal 
and  the  large  ganglionic  cells ;  but,  as  we  proceed  farther  back,  this 
belt  of  granule  cells  deepens,  and,  approaching  the  surface,  eventually 
entirely  displaces  the  small  pyramids,  and  becomes  in  their  place  the 
second  layer  in  this  region.  The  granule-like  aspect  is  due  to  the 
relatively  large  nucleus,  as  comjjared  with  the  investing  protoplasm  : 
they  form  a  belt  of  densely  crowded  elements.  The  cortex,  therefore, 
of  the  area  represented  in  Plate  iv.,  figs.  1-3,  is  constituted  of 

(1)  Peripheral  cortical  zone.  (3)  Ganglionic  belt. 

(2)  Deep  belt  of  granule-like  cells.  (4)  Spindle  cell  layer. 

(3)  Outer  Olfactory  Type. — Passing  now  to  the  lower  limbic  arc 
at  the  base,  we  find  that  the  area  marked  Plate  i.,  B,  has  a  much  simpler 
form  of  cortex  than  those  hitherto  described — two  belts  of  nerve  cells 
only  are  found  in  this  region  subjacent  to  its  outer  or  peripheral  zone. 
This  peripheral  zone  is  specially  characterised  by  the  distribution 
throughout  its  greater  extent  of  fibres  derived  from  the  superficial 
olfactory  fasciculus,  which  lies  embedded  in  this  fix'st  layer  of  its 
cortex;  fibres  which  ramify  at  all  depths  in  this  layer  to  unite  with 
the  meshwork  derived  from  the  apex  pi'ocesses  of  the  cells  beneath. 
Next  to  this,  succeeds  a  shallow  belt  of  irregular  cells,  jjyramidal, 
oval,  or  fusiform,  small  in  size,  each  with  a  bifurcate  apex  process, 
which  immediately  undergo  rapid  subdivision.  They  are  ai'ranged 
in  peculiarly  appressed  clumps.  Then  amongst  them  appear  a  few 
large  cells  of  pyramidal  contour,  which  deeper  down  increase  in 
number  and  foi'm  a  distinct  belt,  in  which  a  few  rather  large  elements 
are  seen.  Traced  outwards,  beyond  the  limits  of  the  great  limbic 
fissure,  these  larger  elements  appear  to  pass  into  the  ganglionic  series. 


TYPES  OP  CORTICAL  LAMINATION.  91 

■whilst  the  small  clumps  of  irregular  cells  pass  into  the  small  pyramidal 
cells  of  the  extra-limbic  region.     This  cortex,  therefore,  comprises 

(1)  A  peripheral  cortical  zone. 

(2)  Dense  appressed  clusters  of  small  cells. 

(3)  Scanty  large  pyramidal  cells. 

(4)  Inner  Olfactory  Type. — Covering  Gratiolet's  "olfactory 
area,"  is  a  three-laminated  cortex,  comprising 

(1)  A  peripheral  zone.         (2)  A  granule  cell  layer. 
(3)  Layer  of  spindle  cells. 

The  second  layer  is  formed  of  cells  measuring  9  /a  x  6  /x,  with  a 
large  spheroidal  nucleus,  6  /i  in  diameter ;  with  these  are  associated 
numerous  minute  granules  only  5  ^  in  diameter,  like  the  gi-anule  cells 
of  the  modified  upper  limbic  region.  This  layer  is  duplicated  in 
numerous  folds,  in  which  the  outer  layer  does  not  participate.  The 
layer  of  spindle  cells  is  notable  for  the  large  size  of  these  elements : 
they  are  reclinate,  i.e.,  their  long  axis  lies  parallel  with  the  surface  of 
the  cortex. 

(5)  Modified  Lower  Limbic  Type. — This  unique  formation,  occu- 
pying the  small  triangular  area,  shown  in  the  figure  (Plate  i.,  T),  is  a 
five-laminated  type,  the  chief  feature  of  which  is  presented  by  its  peculiar 
second  layer  of  cells.  These  nervous  elements  are  more  than  double 
the  size  of  those  occurring  in  the  second  layer  of  the  cortex  elsewhere  ; 
they  are  large,  swollen,  globose,  inflated-looking  cells,  which  almost 
invariably  branch  from  the  apex  by  a  bifid  or  bicorned  process.  This 
belt  of  inflated  cells  is  superimposed  on  a  series  of  small  pyramidal 
bodies,  which  succeeds  them  (Plate  iv.,  fig.  2).  A  pale  belt,  devoid  of 
nerve  cells,  follows  the  latter,  and  is  in  turn  succeeded  by  a  series  of 
spindle  cells.     To  recapitulate,  we  have  here 

(1)  Peripheral  cortical  zone.  (3)  Small  pyramidal  cells. 

(2)  Layer  of  globose  inflated  cells.     (4)  Pale  belt  devoid  of  nerve  cells. 

(5)  Spindle  cell  layer. 

(6)  Extra-LimbiC  Type  difiers  from  that  of  the  upper  limbic 
cortex  solely  in  the  intercalation  of  a  belt  of  granule  or  angular  cells 
between  the  small  pyramidal  and  ganglionic  series.  This  form  of  cor- 
tex exhibits  a  very  gradual  transition  to  the  upper  limbic  type,  and, 
therefore,  presents  an  exception  to  the  rule  of  abrupt  demarcation 
shown  by  other  varieties  of  cortex.     The  gradual  passage  of  one  into 


92  LAMINATION    OF    CEREBRAL    CORTEX. 

another  form  we  sliall  have  reason  to  refer  to  hiter  on;  for  the  present 
it  will  suffice  to  enumerate  tlie  relative  layers  of  this  formation. 

(1)  Pei'ipheral  cortical  zone.     (3)  Belt  of  granule  or  angular  cells. 

(2)  Small  pyramidal  layer.        (4)  Ganglionic  series. 

(5)  Spindle  cell  series. 

(7)  Type  of  the  Cornu  Ammonis. — The  cortex  of  the  comu 

presents  several  features  common  to  other  regions  of  the  hemispheres: 
we  here  have  reproduced  a  peripheral  zone  to  which  run  the  radiate 
apex  processes  of  underlying  cells  :  then  a  dense  belt  of  ganglionic 
cells  :  beneath  which  again  we  trace  a  spindle-form  series  of  elements. 
The  distribution,  however,  of  these  several  nervous  constituents  is  so 
far  different  as  to  stamp  this  type  of  cortex  with  features  peculiarly  its 
own.  Thus,  the  ganglionic  cells  form  a  single  shallow  belt  of  closely 
ap])ressed  elements,  the  apex  processes  of  which,  in  close  serried  file 
radiate  outwards  to  the  peripheral  zone,  no  more  cells,  corresponding 
to  the  second  and  third  layers  elsewhere,  intervening  :  these  radiating 
processes  give  to  this  striate  layeP  the  aspect  from  which  its  name 
is  derived. 

Again,  the  peripheral  zone  is  cleai-ly  divisible  into  two  sections — 
an  outer,  with  tangential,  medullatcd  fibres,  containing  sparsely  scat- 
tered spindle  cells ;  and  an  inner,  which  is  peculiarly  reticulated  in 
aspect,  and  is  constituted  by  a  nerve-fibre  and  a  vascular  meshwork. 
The  former  is  termed  the  nuclear  layer ;  the  latter  the  lacunar 
layer  or  "  stratum  reticulare  "  of  Kupfter.  The  medullated  stratum 
corresponds  to  the  same  stratum  which  is  found  elsewhere  in  the  peri- 
pheral zone,  and  which  we  trace  as  continuous  with  the  underlying 
nerve-fibre  plexus.  The  nerve-fibre  plexus  of  the  reticular  Stratum, 
howevei',  reproduces  that  plexiform  arrangement  which  is  so  well  seen 
in  the  olfactoiy  cortex  {outer  olfactory  type),  and  which  is  there  largely 
constituted  by  the  bifurcate  apex  processes  of  the  cells  of  the  second 
layer.  Here,  however,  in  the  cornu  these  cells  do  not  exist,  and  the 
plexiform  arrangement  is  wholly  that  resulting  from  the  extensions  of 
the  ganglionic  belt,  as  well  as  the  anastomosing  network  of  blood- 
vessels, Avhich  are  here  provided  with  large  perivascular  channels. 

Lastly,  the  spindle  cell  formation  succeeding  the  ganglionic  belt  is 
a  fine,  granular,  faintly-stained  layer,  called  by  Kujjffer  the  "  stratum 
moleculare;"  and  constituted  by  a  fine  meshwork  of  nerve  fibrils — the 
secondary  processes  of  the  superimposed  ganglionic  cells,  in  which 
spindle  cells  are  freely  scattered.  These  latter  elements  are  found  at 
still  deeper  levels,  where  a  pure  white  unstained  stratum — the  deep 
medulla  of  the  coi-nu — appeal's.  In  man  the  stratum  nioleculare  is 
absent,  tlie  axis-cylinders  of  the  ganglionic  cells  uniting  directly  with 


CORNU    AMMONIS — OLFACTORY    BULB.  93 

the  medulla  forming  the  so-called  alveits.  We  may,  thex"efoi"e,  regard 
the  cortex  of  this  region  as  constituted  by 

(1)  The  peripheral  zone  divisible  into — 

(a.)  Nuclear  lamina.  (6.)   Lacunar  or  reticulated  lamina. 

(2)  The  striate  layer.  (3)  The  ganglionic  belt  of  cells. 

(4)  The  spindle  cell  layer  (siratum  moleculare). 

(8)  Type  of  the  Olfactory  Bulb. — A  section  through  the  bulb 

reveals  characters  very  distinct  from  those  hitherto  described,  and  in 
some  particulars  reminds  us  of  the  structure  of  the  retina.  The  outer 
zone  is  constituted  by  a  dense  layer  of  nerve  fibre,  derived  from 
the  olfactory  nerves,  which  here  terminate  in  globular  bodies — the 
olfactory  g'lomeruli.  These  latter  bodies  really  consist  of  fine 
granular  material  imbedding  the  duplicatures  of  an  olfactory  nerve 
fibre,  whilst  small  nuclear  elements  are  also  scattered  through  the 
mass.  The  layer  itself  is  termed  the  stratum  g'lomerulOSUm.  This 
is  succeeded  by  the  stratum  g'elatinosum,  where  fusiform  and 
pyi'amidal  cells  in  more  or  less  scattered  groups  are  found  in  a 
connective  matrix.  Still  deeper  is  an  important  formation  of  very 
densely  grouped,  small  granule  cells  in  distinct  clusters  which  resemble 
closely  the  granule  elements  beneath  the  cells  of  Purkinje  in  the 
cerebellum,  and  which,  imbedded  in  horizontally  disposed  medulla, 
alternate  more  or  less  regularly  with  the  latter.  We  may  enumerate 
as  distinct  layers  of  the  bulbus  olfactorius: — 

(1)  A  peripheral  nerve  layer.  (3)  The  stratum  gelatinosum. 

(2)  The  stratum  glomerulosum.      (4)  The  stratum  granulosum. 


Our  review  of  the  foregoing  types  of  cortical  lamination  in  the 
mammalian  brain  prepares  the  way  for  certain  deductions  which  have 
an  important  bearing  upon  the  physiology  and  pathology  of  the 
cerebrum.  In  the  first  place,  let  us  note  that  the  simpler  forms  of 
cortex  are  confined  to  the  lower  margin  of  the  cortical  en^'elope, 
where  it  folds  round  the  cerebral  peduncle  at  the  base — the  COrnu 

ammonis,  the  lower  limbic  lobe  ("outer  olfactory  type"), 

and  also  the  olfactory  area  of  Gratiolet. 

The  more  complex    form  of  cortex,  however,  spreads  over  the 

upper  limbic  arc  and  the  whole  of  the  extra  limbic  reg-ion  of 

the  hemisphere.  It  is  these  more  complex  forms  of  cortex  Avhich 
concern  us  chiefly  ;  they  comprise  in  man  the  extensive  areas  at  the 
vertex  and  the  whole  convoluted  surface  of  the  hemispheres,  as  seen 
from  above.  Now,  in  studying  the  small  brain  of  the  rodent  and 
hieher  animals  we  find  structural  modifications  in  the  cortex  of  this 


94  DIVERSITIES    OF    COHTICAL    LAMINATION'. 

region,  wliicli  appear  to  forcsliadow  tlie  divergences  observed  in  man. 
Thus,  if  we  examine  successively  the  cortex  at  different  points  from 
within  outwards  in  a  vertical  section  through  the  hemisphere,  passing 
through  the  Sylvian  depression,  we  find  that — 

(a.)  The  first  la^^er  of  the  cortex  is  deepest  at  the  sagittal  border, 
and  steadily  diminishes  in  depth  as  we  proceed  outwards  towards  the 
limbic  fissure ; 

(6.)  The  second  layer  of  small  pyramidal  cells  increases  rapidly  in 
depth  and  in  wealth  of  cell-structure  in  a  reverse  direction — i.e.,  from 
within  outwards ; 

(c.)  The  ganglionic  series  of  cells  (which  assume  thick  clustered 
nests  in  the  tipper  limbic  arc  and  over  the  vertex  bordering  on  the 
sagittal  fissure),  gradually  loses  its  confluent  tendency  and  becomes 
spread  out  in  isolated  units  ("  solitary  type  ")  as  we  approach  the 
limbic  fissui'e  externally.  On  the  other  hand,  if  we  examine  similarly 
a  vertical  section  taken  through  the  posterior  moiety  of  the  upper 
limbic  arc  (Plates  i.  and  ii.)  we  find  that — 

(d.)  The  intercalated  series  of  granule  cells  increases  in  richness  of 
elements  and  depth  of  formation  as  we  proceed  outwards  to  the  lateral 
aspects  of  the  hemispheres,  and  backwards  to  the  occipital  pole ;  and 
reaching  the  limbic  fissure  terminates  abruptly,  whilst  the  other  layers 
pass  on  iminterruptedly.  If  we  now  examine  vertical  sections  of  the 
hemisphere  in  the  antero-posterior  plane,  we  find  that — 

(e.)  The  outer  layer  (peripheral  zone)  progressively  diminishes  in 
depth  from  the  frontal  to  the  occipital  pole ; 

{/.)  The  small  pyramidal  cells  of  the  second  layer  diminish  in  size 
in  the  same  direction  ; 

(g.)  The  granule  or  angular  cells  intercalated  in  the  five-laminated 
coi'tex  increase  in  richness  conspicuously  towards  the  occipital  pole  ; 

(Ji.)  Lastly,  the  ganglionic  series,  which  near  the  frontal  pole  forms 
a  deep  layer  rich  in  cell  elements,  thins  out  considerably  backwards 
into  a  laminar  or  "  solitary  "  formation  ;  but,  at  the  extreme  occipital 
pole,  these  cells  again  form  a  somewhat  deep  belt  with  granule  cells 
superimposed. 

The  obvious  deductions  to  be  made  from  the  foi-egoing  are  that 
certain  elements  preponderate  in  certain  fixed  areas  of  the  cortex ; 
and  that  the  development  of  certain  layers  appears  to  exclude  that  of 
another  series.  Thus  the  frontal  pole  and  frontal  extremity  of  the 
tipper  limbic  arc  are  es})ecially  characterised  by  the  preponderance  of 
the  g'ang'lionic  series,  which  accumulates  here  in  rich  clustered 
groups  ;  towards  the  .Sylvian  border  this  element  is  insignificant,  and 
it  is  the  small  pyramidal  layer  which  here  prevails.  Towards  the 
occipital  pole  mesially  ("  modified  upper  limbic  type  ")  the  granule 


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REGIONAL    DISTRIBUTION    OP    GANGLIONIC    CELLS.  95 

cell  attains  like  importance  from  its  notable  wealth  of  elements  and 
its  more  or  less  complete  exclusion  of  the  small  pyramidal  series;  wliilst 
outside  this  formation,  in  the  extra  limbic  cortex,  the  intercalated 
granule  belt  is  a  notable  feature,  accompanying  a  corresponding 
impoverishment  of  the  small  pyramidal  and  ganglionic  series. 

A  certain  relationship  also  would  seem  to  exist  between  the  depth 
of  the  first  layer  or  peripheral  zone  and  the  ganglionic  series  of  cells  ; 
since  it  notably  diminishes  in  depth  as  these  elements  thin  out  into 
the  solitary  type  of  arrangement,  and  this  despite  the  marked  increase 
in  the  small  pj^ramidal  series  above.  This  mutual  dependence  seems 
to  us  explained  by  the  fact  that  the  apical  processes  of  these  large 
elements  pass  up  into,  and  terminate  in,  this  peripheral  zone,  so  that 
any  regional  difference  in  the  depth  of  the  outer  layer  will  be  dependent 
on  the  greater  or  less  development  of  these  ganglionic  cells.  It  must 
be  borne  in  mind,  however,  that  the  average  depth  of  the  first  layer 
increases  in  lower  mammals  and  becomes  shallower  as  we  rise  to  the 
more  highly  organised  brains — a  fact  which  does  not  militate,  as  might 
at  first  appear,  against  the  preceding  conclusion.  In  the  lower 
mammals,  the  absolute  and  relative  increase  in  the  depth  of  this  outer 
layer  probably  means  a  large  preponderance  of  the  connective  over 
the  nervous  element.* 

Reg-ional  Distribution   of  the   Ganglionic   Cell.— Attention 

was  first  dii'ected  to  the  peculiai'ly  clustered  arrangement  of  these  cells 
in  the  cortex  of  man  and  the  higher  apes  by  Professor  Betz,-j-  who 
denominated  them  "giant  pyramids,"  and  suggested  their  probable 
motor  signification  from  their  form,  arrangement,  and  connections. 
Subsequent  research  appears  fully  to  confirm  the  conclusion  arrived  at 
by  Betz,J  and  it  becomes,  therefore,  important  to  indicate  the  regional 
distribution  of  these  elements.  We  find  that  this  series  of  cells  in  man 
and  the  higher  mammals  (Pig,  Sheep,  Dog,  Cat,  Ape,  and  Man)  assumes 
in  separate  regions  of  the  cortex  a  different  arrangement,  which  we  have 

*  See  upon  this  point,  Meynert,  "Brain  of  Mammals,"  Si/d.  Soc,  p.  3S3 ;  also, 
Brain,  vol.  i.,  p.  358. 

t  "Anatomischer  Nachweis  zweier  Gehirucentra,"  Prof.  Betz,  Centralhlatt  f.  d. 
Med.  WisseMsch.,  Aug.,  1884. 

J  It  is  true  that  Mej'nert  would  dispose  of  the  assumed  significance  of  these  cells 
on  the  grouud  that  their  large  size  depends  on  the  distance  which  their  apical 
process  has  to  traverse  in  reaching  the  outer  layer,  and  their  gradual  mcrease  iu 
dimensions  being,  as  he  states,  proportionate  to  this  distance.  The  "gradual 
increase  in  size  "  alluded  to  proves  to  us  that  Meynert  has  failed  to  identify  the 
elements  referred  to — probably  mistaking  for  them  the  larger  pyramids ;  and  finally 
his  argument  falls  to  the  ground  when  it  is  seen  that  the  second  layer  of  the 
"  modified  lower  limbic  type  "  contains  larger  elements  than  any  of  its  subjacent 
layers. 


96  COMPARATIVE    STUDY    OF    CORTICAL    LAMINATION. 

termed  the  clustered  or  nested  and  the  laminar  or  solitary 

arrangement'' — the  former  showing  tliese  large  cells  aggregated  into 
distinct  oval  clusters  stationed  at  intervals  apart — the  latter  ap- 
proaching the  arrangement  of  these  cells  universally  met  with  at  the 
base  of  a  sulcus,  viz. : — solitary  cells,  stationed  like  sentinels  wide  apart, 
showing  no  tendency  to  gi-ouping  beyond  two  or  three  at  most  in 
certain  exceptional  areas.  In  lower  mammals  (Rabbit  and  Rat),  these 
discrete  or  distant  clusters  do  not  appear ;  but  what  we  take  to  be  the 
homologue  of  this  series  forms  COnfluent  grOUpS — the  nested 
arrangement  being  scarcely  indicated,  and  a  deep  and  dense  formation 
replacing  the  latter.  As  ali-eady  observed,  however,  these  confluent 
groups  thin  out,  in  certain  regions,  into  linear  file,  assuming  the 
laminar  or  solitary  arrangement.  The  cells  of  this  series  in  these 
lowly-organised  brains  are  peculiar  in  their  extremely  elongate  pyra- 
midal or  fusiform  contour,  and  approach  in  this  respect  the  form  of  the 
larger  fyramiids  in  the  human  cortex  rather  than  the  configuration  of 
the  motor  cell.  As  we  pass  from  the  confluent  groups  of  elongated 
elements  in  the  Rodent  to  the  more  specialised  areas  of  higher 
mammals,  we  find  that — 

(1)  The  cells  become  less  elongate,  more  swollen,  and  irregular  in 
contour  ; 

(2)  Their  groupings  become  more  and  more  discrete  ; 

(3)  The  individual  groups  grow  larger  in  size ; 

(4)  The  clustered  arrangement  occupies  a  wider  range  of  cortex. 

In  Plate  i.  this  series  of  cells  is  richly  represented ;  they  are 
densely  congregated  towards  the  margin  of  the  hemisphere,  and  thence, 
continued  to  the  limbic  fissure,  occupy  the  whole  area  embraced  by 
Nos.  7  and  9  in  Terrier's  work.f  Further  back,  however,  this  layer 
diminishes  in  depth  and  in  wealth  of  cells,  except  at  the  exposed 
margin  of  the  hemisphere,  where  it  still  remains  a  rich  formation; 
beyond  the  margin  and  over  the  extra-limbic  region,  as  fiir  as  the 
limbic  fissure,  the  cells  rapidly  thin  out  into  a  simple  linear  series,  and 
the  five-laminated  cortex  appears.  Still  further  back  the  series,  in  like 
mannei",  thins  out  into  a  mere  insignificant  formation — yet  always  most 
richly  developed  along  the  sagittnl  margin  of  the  hemisphere. 

Plate  ii.,  fig.  1,  rej)resents  the  ai-rangement  of  the  ganglionic  series 
in  the  Pig,  the  regional  distribution  of  which  is  almost  identical  in 
formation  with  that  of  the  Sheep.  For  both  these  animals, 
it  may  be  stated,  that  a  Jive-laminated  cortex,  with  clustered  cell- 
groups^  spreads  over  the  anterior  half  of  the  upper  limbic  arc  (which 

*  "Comparative  Structure  of  Cortex  Cerebri,"  Tranx.  Hot/.  Soc,  part  i.,  1880. 
i  Functions  of  the  Brain,  second  edition,  p.  259,  fig.  78. 


THE    CORTEX    OF    THE    PIG,    SHEEP,    CAT,    APE,    ETC.  97 

in  these  animals  becomes  superficial  on  the  upper  aspect  of  the  hemi- 
sphere) over  the  frontal  pole  and  along  the  first  (or  Sylvian)  and 
second  parietal  convolution.  Between  these  tracts  is  embraced  the 
area  of  the  third  and  fourth  parietal  convolutions,  which  have 
a  six-laminated  cortex  and  a  distinctly  solitary  arrangement  of  these 
cells. 

If  we  examine  the  regional  distribution  in  the  Cat,  the  anterior 
portion  of  the  upper  limbic  arc  in  front  of  and  above  the  crucial 
sulcus;  the  frontal  lobe;  the  first  parietal,  or  Sylvian;  and  the  anterior 
extremity  of  the  fourth  parietal  or  sagittal  convolution,  will  all 
be  found  to  exhibit  the  laminated  cortex  and  nested  cells ;  yet  the 
formation,  excessively  rich  in  the  sigmoid  gyri  around  the  crucial 
sulcus,  becomes  much  poorer  in  other  regions.  The  six-laminated 
type  extends  over  the  whole  extent  of  the  upper  limbic  arc,  behind 
the  crucial  sulcus,  as  far  back  as  the  retro-limbic  annectant. 

The  distribution  of  these  nested  groups  of  ganglionic  cells  in  the 
ocelot,  reproduces,  in  fact,  very  nearly  the  arrangement  met  with  in 
the  cat. 

The  distribution  of  the  same  formation  in  the  Barbary  ape  fore- 
shadows the  arrangement  which  pertains  to  the  more  highly  developed 
cortex  of  man. 

It  will  be  observed  from  the  foregoing  remarks  that  the  CPUCial 
sulcus  in  all  these  animals  foi-ms  a  distinct  limit  to  two  types  of 
lamination — peculiar  to  the  vertex — the  flVG-  and  the  siX-laminated. 
types,  and  that  this  distinction  is  continued  upon  the  mesial  aspect 
of  the  hemisphere  into  which  this  sulcus  extends ;  that,  similarly,  at 
the  frontal  pole  of  the  hemisphere,  the  vertical  sulcus,  regarded  by 
Broca  as  the  representative  of  the  fissure  of  Rolando,  also  separates 
an  inner  or  five-laminated  from  an  outer  or  six-laminated  cortex ; 
whilst  the  first  parietal  or  Sylvian  convolution  in  the  pig  and 
sheep  partakes,  in  front  of  the  Sylvian  fissure,  of  the  five-laminated 
type. 

In  1882,*  after  a  minute  enquiry  into  the  cortical  envelope  of  the 
brain  in  mammals,  the  author  had  reason  to  express  himself  as  follows  : 
— "The  more  fully  I  investigate  the  minute  structui-e  of  the  cortex  and 
its  deep  connections,  the  more  forcibly  am  I  impressed  with  the  belief 
that  the  vai'ious  fissui'es  and  su.lci  are  not  mere  accidental  productions,+ 
but  have  a  deep  significance  of  their  own,  dividing  oft'  the  cortical 
superficies  into  morphologically,  if  not  ijhysiologically,   distinct  organs. 

*  Op.  cit. ,  page  724. 

t  That  is,  the  result  of  pressure  merely,  during  the  development  of  the  cranial 
arch. 

7 


98  COMPARATIVE    STUDY    OF    COUTICAL    LAMINATION'. 

Hitherto  the  fissures  and  sulci  wliich  I  liave  found  to  be  boundary- 
lines  of  distinct  cortical  realms  are  the  following  : — 

"(1)  The  limbic  fissure.  (4)  The  superior  parietal  sulcus. 

{2)  The  infra-parietal  sulcus.  (5)  The  interparietal  sulcus. 

(3)  The  crucial  sulcus.  (6)  The  olfactory  sulcus. 

(7)  The  fissure  of  Rolando." 

Contrasts  between  the  Brain  of  Man  and  of  Lower  Mam- 
mals.— When  we  contrast  the  cortex  of  the  human  brain  and  of  the 
ape  with  that  of  the  mammalian  series  below  these  types,  certain 
strongly-marked  resemblances  in  intimate  structure,  as  well  as  equally 
notable  divergences,  present  themselves.  With  respect  first  to  the 
resemblances,  it  is  to  be  noted  that  the  various  types  of  cortical 
lamination  described  in  the  lower  mammals  are  reproduced  in  the 
brain  of  the  ape  and  man ;  and  that  the  several  layers  maintain  the 
same  relative  position  throughout  their  depth,  except  where  in  certain 
cases  a  layer  is  wanting,  or  a  new  layer  is  interposed.  Again,  the 
individual  elements  constituting  these  layers — the  granule  cell,  the 
angular  cell,  the  spindle,  the  pyramidal  element — although  differing 
somewhat  in  dimensions  and  general  contour,  are  yet  sufficiently  alike 
for  their  identification  apart  from  their  mere  position  in  the  cortex. 

In  the  next  place,  the  lower  limbic  margin  of  the  coi'tical  envelope 
always  presents  the  simpler  forms  of  cortex;  while,  towards  the  vertex 
and  mesially  both  towards  frontal  and  occipital  poles,  the  more  complex 
forms  of  cortex  pi'evaiL  Another  sti'iking  resemblance  occurs  in  the 
distribution  of  these  laminar  types — that  characterised  by  the  g'ranule 
cell  predominating  towards  the  OCCipltal  pole ;  that  of  the  five- 
laminated  type  being  especially  developed  towards  the  frontal  pole  : 
with  this  there  is  associated  finally  the  gradual  diminution  in  size  of 
the  one  element  towards  the  temporal  and  occipital  lobe,  and  the 
increased  dimensions  and  richness  of  formation  of  the  other  element  in 
the  same  direction.  These  are  some  of  the  more  striking  resemblances 
presented  between  the  cortex  cerebri  of  roan  and  that  of  the  lower 
mammals. 

As  to  the  diverg'ences  presented  by  these  structures,  we  are  early 
struck  by  the  fact  that  the  abruptness  Of  transition  from  one  to 
another  type  of  cortex,  seen,  e.(/.,  in  the  rodent,  is  not  a  feature  in  the 
human  brain;  in  fact,  transition-realms  invariably  intervene  betwixt 
different  types  of  lamination.  The  one  fades  into  the  other  form  so 
gradually  that  a  line  of  demarcation  can  rarely  be  drawn.  Thus,  the 
five-laminated  cortex  characterising  the  "motor  area"  of  the  human 
brain  affords  no  abrupt  transition  into  the  six-laminated  cortex  lying 


THE    MOTOR    AREA    IN    MAN.  99 

external  and  posterior  to  it ;  a  mixed  type  intervenes,  to  which  we 
have  applied  the  term  of  "transition-realm." 

In  the  second  place,  the  cells  which  we  have  ventured  to  term 
"  motor  "  in  the  fourth  layer  of  the  human  cortex,  ditfer  from  what  we 
have  regarded  as  the  homologous  series  in  lower  mammals,  in  being 
restricted  as  a  typical  formation  to  a  comparatively  limited  area  of  the 
cortex — that  of  the  rodent,  e.g.,  being  spi-ead  over  a  far  wider  propor- 
tionate area  of  the  hemisphere.  This  concentration  of  these  cell- 
groups  is  best  seen  in  carnivora,  where,  as  already  shown,  they  crowd 
around  the  crucial  sulcus,  especially  at  the  angle  of  the  sigmoid  gyrus. 
They  exhibit  the  tendency  in  a  less  marked  degree  in  the  higher  apes 
whilst  in  miin  they  are  concentrated  in  three  or  four  districts  occupy- 
ing, as  before  stated,  but  a  comparatively  limited  area.  A  still  more 
notable  distinction  between  the  higher  and  lower  forms  of  brain 
presented  by  this  formation,  is  the  nested  arrangement  observed  by 
Betz  in  the  human  brain.  This  segregation  is  complete,  the  groups 
being  large  and  far  apart.  As  we  descend  the  scale,  however,  the 
more  do  we  observe  the  tendency  for  such  gi'oups  to  become  confluent, 
and  the  series  to  be  disposed  as  an  equable  stratum. 

Lamination  of  the  Motor  Area  in  Man.— That  region  of  the 

cortex  which  has  been  shown  in  animals  to  be  electrically  excitable, 
and  which  upon  stimulation  calls  forth  responsive  movements,  has 
been  termed  the  "motor  area."  It  is,  as  we  have  just  seen,  charac- 
terised by  a  highly  specialised  structural  arrangement.  It  is  all  the 
more  essential  that  its  structure  in  man  should  be  clearly  defined 
here,  since  it  has  been  the  subject  of  dispute  between  such  writers  as 
Meynert,  Betz,  Baillarger,  Mierzejewski,  and  others,  some  authox'ities 
speaking  of  it  as  a  five-laminated  and  others  as  a  six-laminated  type. 
At  the  outset,  therefore,  it  is  well  to  define  our  own  view  of  the  case, 
which  is  briefly  as  follows  : — The  cortex  typical  of  motor  areas  is  a 
flve-laminated  formation,  and  the  more  absolutely  the  granule- 
cell  formation  (which,  when  intercalated,  gives  us  the  six-laminated 
type)  is  excluded,  the  more  highly  specialised  become  those  groups  of 
enormous  nerve  cells  which  go  by  the  name  of  the  "  nests "  of  Betz. 
Where,  therefore,  these  cell-clusters  are  best  represented,  there  we 
find  a  five-laminated,  not  a  six-laminated,  cortex ;  in  other  words,  at 
these  sites  the  granule-cell  layer  no  longer  exists.  Such  a  specialised 
cortex  is  not  spread  uniformly  over  a  large  convolutionaiy  surface  at 
the  vertex — any  such  notion  would  be  very  far  from  correct ;  but  it 
occupies  very  irregular,  limited,  and  unequal  areas  along  the  course  of 
the  ascending  frontal  and  the  junctions  between  it  and  the  frontal 
gyri,  as  well  as  the  "paracentral  lobule."  These  positions  we  shall 
more  clearly  define  later  on. 


100  THE  CORTKX  CEREnUI  IN  MAN. 

Such  irregularly-disposed  ivreas  are  severed  from  each  other  by  a 
transitional  form  of  lamination,  whereby  these  districts  gradually 
merge  into  the  six-laminated  cortex  surrounding  them.  This  highly- 
specialised  cortical  formation  is  constituted  as  follows  : — 

First  Layer. — An  extremely  delicate  pale  zone,  devoid  of  nerve 
cells,  limits  the  cortex  externally ;  it  i)resents  all  the  features  already 
described  as  peculiar  to  the  cortical  neuroglia  (see  p.  79).  The  outer 
surface,  upon  which  the  intima  pia  I'ests,  presents  numerous  flattened 
cells,  from  which  excessively  delicate  processes  pass  downwards  into 
this  layer.  These  cellular  elements  are  often  found,  detached  from 
fresh  sections,  floating  in  the  medium  around  ;  they  form,  in  fact,  a 
kind  of  epithelial  limiting  layer,  extremely  delicate  and  translucent. 
This  first  layer,  or  perijjheral  zone,  exhibits  a  pellucid  homogeneous 
matrix  (becoming  finely  molecular  with  reagents)  and  three  structural 
constituents — (a.)  cellular,  (b.)  nerve  fibi-e,  (c.)  vascular. 

(a.)  The  cellular  constituents  are  not  numerous,  are  widely  dispersed, 
and  belong  to  the  two  categories  of  the  perivascular  or  adventitial 
elements  and  the  elements  of  the  lymph-connective  system  already 
referred  to  (p.  83).  The  former  measure  6  /x  to  9  ^  in  diameter, 
possess  a  spheroidal  nucleus,  stain  well,  and  are  seen  disposed  along 
the  course  of  the  blood-vessels.  The  latter  often  measure  13  jti  ill 
diameter,  possess  one  and  occasionally  two  or  three  nuclei,  are  spher- 
oidal, flask-shaped,  or  irregular  in  contoui',  stain  uniformly  and  very 
faintly,  and  throw  off  numerous  excessively  delicate  pi'ocesses,  which 
in  healthy  fresh  cortex  can  only  be  distinguished  with  difliculty. 

(b.)  The  nervous  constituents  embrace  a  series  of  medullated  fibres, 
which  course  along  the  outer  division  of  this  zonular  layer,  and  a 
minute  network  of  the  non-medullated  fibres  ai'ising  from  the  cells  of 
the  subjacent  layers  by  the  subdivision  of  their  apex  processes. 

(c.)  The  vascular  elements  pass  as  long  straight  vessels  for  deep 
distribution,  and  as  shoi't  branched  and  smaller  vessels  through  its 
structure ;  they  call  for  no  special  remark  here. 

Second  Layer. — A  narrow  belt  of  very  closely  aggregated  nerve 
cells  of  irregular  marginal  contour,  oval,  pyramidal,  or  angular,  with 
a  proportionately  large  nucleus,  forms  this  stratum.  The  cells  vary 
much  in  size,  and,  as  we  have  previously  remarked,  are  much  more 
richly  developed  in  some  than  in  other  regions  of  the  brain.  They 
measui'e  from  11  /i  to  23  //-  in  length,  6  /a  to  9  ^  in  breadth,  the 
nucleus  being  often  6  /i  in  diameter.  They  exhibit  numerous  delicate 
processes,  radiating  from  the  base  and  sides ;  but  a  distinct  apical 
process  or  frequently  a  bi-corned  apex  passes  up  radially  to  the  surface 
of  the  cortex  and  undergoes  rapid  subdivision. 

Third  Layer. — Subjacent  to  the  above  lies  a  deep  belt  of  nerve 


THE    MOTOR    AREA    IN    MAN.  101 

cells,  the  elements  of  which  are  characterised  by  their  more  or  less 
elongated  or  pyramidal  contour,  and  by  the  tendency  to  gradual 
increase  in  their  size  as  they  lie  deeper  in  the  cortex.  The  summit  of 
these  cells  is  elongated  into  a  long  delicate  apex  process,  which  passes 
radially  upwards  towards  the  peripheral  zone.  The  opposite  pole 
of  the  cell  is  irregularly  dentated  by  the  extension  of  numerous 
delicate  processes,  which  are  thrown  off  from  the  cell  in  all  directions 
around  :  none  of  these  processes  turn  upwards  and  pursue  the  course 
of  the  apex  process.  The  dimensions  of  these  cells  in  the  outermost 
zone  average  12  /^  x  8  /x;  those  of  the  deeper  regions  of  this  layer 
23  iM  up  to  even  41  /x  in  length,  and  23  /x  in  shorter  diameter.  Each 
cell  possesses  a  large  nucleus  and  a  distinct  nucleolus.  Small  pyramidal 
cells,  however,  no  larger  than  those  at  the  commencement  of  this  layer, 
occur  even  at  the  deepest  part,  side  by  side  with  the  largest. 

Fourth  Layer.— This  layer  presents  us  with  the  highly  charac- 
teristic nerve  element  which  we  have  already  dealt  with  under  the 
name  of  ''motor  cell.'"'  These  great  elements  are  found  modified  in 
different  cortical  realms  as  follows  : — 

(a.)  In  the  highest  regions  of  the  motor  area  (summit  of  central  gyri 
and  paracentral  lobule)  they  are  not  only  of  gigantic  size,  as  compared 
with  other  nerve  cells  around,  but  they  form  here  the  large  clusters 
recognised  by  Betz. 

(6.)  In  the  lowest  regions  of  the  motor  area  (lower  end  of  central  and 
junction  with  third  frontal  gyrus)  they  become  small  in  size,  even  less 
than  the  superjacent  elements  of  the  third  layer,  but  still  retain  their 
clustered  disposition. 

(c.)  Towards  every  sulcus  these  cells,  be  they  large  or  small,  lose 
their  groupings,  and  at  the  base  of  the  sulcus  they  always  assume  the 
drawn-out  single  file,  spoken  of  as  the  "  solitary  "  type  of  arrangement. 
{d.)  Lastl}^,  as  this  laminar  type  passes  into  that  of  the  sensory 
realms,  these  cells  have  superimposed  on  them  a  layer  of  granule 
cells,  but  still  retain  a  somewhat  clustered  disposition  so  characterising 
the  transitional  cortex;  and  they  ultimately  assume  the  solitary  arrange- 
ment always  seen  in  a  sulcus,  throughout  the  convolution  at  all  heights, 
becoming,  in  fact,  the  six-laminated  cortex  typical  of  sensory  areas. 
Such  are  the  modifications  undergone  by  these  elements  at  different 
localities  in  the  cortex. 

Fifth  Layer.— This  layer  is  represented  by  the  series  of  spindle-cells, 
which  beneath  the  summit  of  a  convolution  are  disposed  radially  to 
the  surface  in  regular  columns,  separated  by  bundles  of  medullated 
fasciculi,  ascending  from  the  central  medullated  core  of  the  gyrus. 
Towards  a  sulcus  they  lose  this  radial  disposition,  and  at  the  bottom 
of  the  sulcus  are  disposed  in  a  narrow  belt,  their  long  axes  horizontal 


102 


THE    CORTEX    CEREBRI    IN    MAN. 


to  the  surface,  a  position  aptly  termed  reclinale.  by  Dr.  Major.  These 
cells  measure  from  25  (j,  to  32  /x  in  length,  by  9  /x  to  13  /i.  in  breadth, 
and  exhibit  a  large  oA-al  nucleus. 

Distribution  of  the  Motor-cell  Groups.— The  specialised  five- 
laminated  cortex,  with  the  cell  clusters  above  referred  to,  has  been 
stated  to  occupy  certain  areas  of  the  ascending  frontal,  the  three  frontal 
gyri  and  the  "  imracentral"  lobule  ;  it  remains  for  us  to  indicate  more 
])articularly  the  exact  site  occupied  by  this  type.  In  the  scheme  now- 
presented,  the  I'esults  of  an  investigation  into  the  localisation  of  these 
areas  in  eight  human  brains,  made  in  1878  by  the  author  in  conjunction 
with  Dr.  Heniy  Clarke,  are  given.*     The  arrangement  and  distribution 


Fig.  8. — Left  ascending  frontal  and  parietal  convolutions  seen  from  the  side,  with 
the  attached  frontal  gyri  included  in  scheme  of  examination. 

H-K,  Third  group  of  ganglionic  cells.  N-0,  Fourth  group  of  ganglionic  cells. 

M-N,  Barren  area.  11,  Region  of  large  elongate  cells. 

P,  Fifth  group  of  ganglionic  cells. 


•were  strangely  uniform  in  all  these  cases  (see  figs.  8  and  9).  Variations 
in  the  extent  of  these  areas  of  course  presented  themselves,  but  not  to 
such  an  extent  as  to  vitiate  the  general  result  arrived  at,  viz.,  that 
such  cell-clusters  wei-e  grouped  into  several  distinct  areas,  very  clearly 
and  definitely  interrupted   by   the   transitional  type   of  cortex.     The 

*  "The  Cortical  Lamination  of  the  Motor  Area  of  the  Brain,"  by  Bevan  Lewis 
and  Henry  Clarke,  Proc.  Hoy.  Soc,  No.  185,  1878. 


MOTOR    CELL-GROUPINGS.  103 

variations  in  the  extent  of  such  areas  are  no  more  than  nii^ht  be 
anticipated  from  the  developmental  variations  indicated  by  tlie  form  of 
the  central  and  neighbouring  gyri.  The  upper  end  of  the  ascending 
frontal  and  its  junction  with  the  upper  frontal  gyrus  are,  as  is  well 
known,  very  variable  in  form  and  complexity,  and  such  variations  are, 
in  our  opinion,  closely  related  to  the  more  or  less  rich  development  of 
the  specialised  cortex  under  consideration.  Reference  to  the  scheme 
shows  us  that  the  ascending  frontal  gyrus  may,  in  general,  for  con- 
venience of  description  be  considered  as  consisting  of  two  seo-ments — 
an  upper,  com^jrising  two-thirds  its  length,  into  which  run  the 
superior  and  middle  frontal;  and  a  lower,  comprising  the  remainino- 
third,  continuous  with  the  inferior  frontal  in  front,  and  with  the 
ascending  parietal  behind. 

Taking  first  the  upper  two-thirds,  we  find  that  the  i;pper  end  has 
a  somewhat  broad  attachment  to  the  upper  frontal.  The  lower  end 
receives  the  middle  frontal  usually  as  a  narrower-folded  convolution, 
whilst  between  either  junction  a  sinuous  knee-like  bend  of  the  convo- 
lution exists.     The  broad  upper  extremity  continuous  with  the  upper 


R--.. 


Fig.  9. — Left  ascending  frontal  and  parietal  gyri,  with  the  attached  frontal 
convolutions,  as  seen  at  the  vertex. 

*A-D,  First  group  of  ganglionic  cells.  M-N,  Barren  area. 

E-G,  Second        ,,  ,,  N-0,  Fourth  group  of  ganglionic  cells. 

H-K,  Third         ,,  ,,  R,  Region  of  large  elongate  cells. 

frontal  is  the  site  of  two  important  clustered  groups  (A-D  and  E-G)  ; 
the  plump  lobule  intervening  between  both  upper  frontals  is  the  site 
of  tAvo  other  similar  groups  (II-K) ;  lastly,  the  extreme  posterior  end 
of  the  middle  frontal  gyrus  shows  similar  cell-groupings  (N-0),  the 
areas  of  which  extend  into  those  of  the  ascending  frontal  at  their  lines 
of  attachment. 

The  upper  group  (A-D)  presents  by  far  the  larger  cells  and  the  more 


104  THE  CORTEX  CEREBRI  IN  MAN, 

perfect  and  dense  clusters.  Such  clusters  occupy  especially  the  parietal 
aspect  of  the  convolutiun,  which  is  adjacent  to  the  ascending  parietal 
convolution.  They  appear,  therefore,  in  the  cortex  forming  the  wall 
of  the  Kolandic  fissure,  and  creep  up  towards  the  summit,  where  they 
rapidly  thin  out  and  disappear. 

The  second  group  (E-G),  connected  with  the  lower  attachment  of  the 
upper  frontal,  is  entirely  restricted  to  the  frontal  aspect  of  this  gyrus, 
and  does  not  overleap  the  confines  of  the  vertex  and  spread  into  the 
Rolandic  fissure,  except  at  its  most  inferior  part. 

Tlie  third  group  (H-K)  forms  a  large  area,  covering  the  parietal  or 
Rolandic  wall  of  its  knee-like  lobule  (upper  two-thirds),  and  spreads  over 
the  vertex  of  the  convolution  at  this  site.  Between  it  and  the  fourth 
group  occurs  a  narrow  territory  wholly  devoid  of  this  formation; 
transitional  cortex  extending  until  we  reach  the  latter  group. 

At  the  junction  of  tlie  middle  frontal  (N-O). — This  group,  as  before 
stated,  becomes  continuous  with  that  of  the  middle  frontal ;  it  also 
begins  within  the  fissure  of  Rolando  and  sweeps  over  the  vertex. 

The  fifth  and  sixth  groups  (P)  are  indicated  approximately  on  the 
scheme,  but  appear  subject  to  considerable  variations  in  extent. 

To  the  foregoing  groups  must  be  added  a  further  area,  occupying  the 
posterior  two-thirds  of  the  lobule  on  the  inner  or  mesial  aspect  of  the 
central  gyri,  lying  in  front  of  the  fissure  of  Rolando  and  above  the 
gyrus  fornicatus,  usually  termed  tlie  paracentral  lobule.  Some  enor- 
mous cells  are  found  in  the  grouping's  of  this  area. 

Transition-Realms  of  Motor  Cortex.— It  will  be  observed  that, 

in  the  above  enumeration  of  specialised  areas,  we  have  by  no  means 
covered  the  ground  assigned  to  the  motor  area  by  Prof.  Ferrier  :  the 
lower  end  of  the  ascending  frontal,  the  whole  of  the  ascending  parietal, 
as  well  as  the  postero-parietal  lobule  have  been  omitted.  In  fact, 
these  latter  regions  do  not  exhibit  the  specialised  cortex  referred  to, 
but  are  covex'ed  by  cortex  transitional  in  its  character  between  the 
former  and  what  we  find  existing  in  sensory  realms.  If,  for  instance, 
the  upper  extremity  of  the  ascending  parietal  be  subjected  to  examina- 
tion, we  find  that  its  anterior  aspect,  dipping  down  into  the  Rolandic 
fissure,  also  possesses  large  ganglionic  cells  similar  to  those  in  the 
motor  area  in  advance  of  this  site.  The  nests  or  clusters,  however, 
are  not  only  thinly  scattered,  but  contain  few  cells,  and  the  latter 
diminish  rapidly  in  size  at  lower  levels  along  this  convolution;  it  is 
only  at  the  upper  extremity  of  the  gyrus  that  large  cells  are  found. 
Throughout  by  far  the  greater  extent  of  this  convolution,  the  cells  of 
this  layer  are  exact  representatives  of  those  found  in  the  ascending 
frontal,  hut  are  greatly  diminislied  in  size,  and  although  often  arranged 
in  clustered  groups,  the  groups  are  poor  in  elements  and  sparse. 


TUAN8ITI0N-REALMS    AND    SPKCIALISED    AREAS.  105 

The  major  distinction  between  the  transitional  and  specialised  motor 
cortex  is  in  the  presence  of  a  gradually  increasing  belt  of  small 
pyramidal  or  angular  cells,  which  are  almost  identical  with  those  of 
the  second  layer,  and  which  here  insinuate  themselves  between  the 
largest  cells  of  the  third  layer  and  the  sparse  nests  of  the  ganglionic 
cells.  Thus,  with  the  fading-off  of  this  rich  clustered  formation,  we 
get  the  intercalation  of  an  entirely  new  layer  of  elements,  which  grows 
in  importance  as  we  approach  sensory  realms.  Now  the  whole  ascend- 
ing parietal,  postero-parietal,  and  lower  end  of  the  ascending  frontal 
divisions,  partake  of  this  six-laminated  type  of  cortex  ;  and,  moreover, 
as  we  approach  the  margin  of  the  brain-mantle— i.e.,  the  lower  end  of 
the  central  gyri — the  "motor"  cells  become  smaller  and  yet  smaller, 
forming  eventually  insignificant  clusters  of  minute  elements.  Eoughly 
stating  the  case,  we  may  say  that  the  fissure  of  Rolando,  in  the  upper 
two-thirds  of  its  extent,  separates  the  typical  motor  cortex  from  the 
transitional  cortex;  whilst,  in  like  manner,  the  interparietal  fissure 
is  the  boundary  between  the  transitional  and  the  typical  sensory  cortex 
below  and  posterior  to  it. 

It  will  be  apparent  from  the  foregoing  chapter  on  the  histological 
structure  of  the  cortex  cerebri  that  its  many  varieties  of  type  depend, 
for  the  most  part,  upon  the  operation  of  one  or  more  of  the  following 
circumstances.     There  may  be — 

(1)  Inverse  development  of  superimposed  layers— such,  for  in- 
stance, as  was  noted  in  the  rodent's  brain,  where  the  third  layer  of 
cells  invariably  became  shallower  with  increasing  richness  of  the 
second  layer  of  angular  elements  and  vice  versa.  As  the  one  formation 
tends  to  die  out,  the  other  tends  to  increase  in  thickness  and  density. 

(2)  Substitutional  StPatification  may  occur— i.e.,  a  layer  of 
cells  may  have  other  elements  mixed  with  it,  and  gradually  pre- 
ponderating to  the  exclusion  of  its  own  cells,  and  then  a  change 
in  type  may  occur;  e.g.,  the  granule  cells  may  gradually  intermingle 
with  the  angular  elements,  and  excluding  them  entirely,  form  a  deep 
belt  in  their  place,  or  vice  versd. 

(3)  Intercalation  of  new  layers,  as  in  the  appearance  of  a  six- 
laminated  type,  where  the  angular  elements  gradually  insinuate 
themselves  between  the  third  layer  of  pyramidal  cells  and  the  sub- 
jacent ganglionic  series.  Or,  again,  an  altered  type  of  cortex  may 
proceed  from — 

(4)  An  unusual  development  of  the  elements  of  a  certain  layer,  as 
when  the  angular  element  of  the  second  layer  develops  into  tlie  large 

globose  cell  of  this  layer  in  the  modified  lower  limbic  type  of 

the  Rat,  Rabbit,  Mole,  &c.;  or  where  the  elements  of  the  fifth  layer  in 
the  sensory  cortex  become  changed  into  the  large  complex  cells  of  the 


106  TIIK    CORTEX    CEREBRI    IN    MAN. 

motor  grouping's.  As  we  traverse  the  whole  range  of  tlie  cortex, 
one  or  other  of  the  above  influences  is  at  work  in  modifying  its 
form  of  stratification. 

Passing  now  from  the  question  of  cortical  lamination  to  the  cell 
itself,  its  conditions  of  life  and  functional  activity,  and  its  relationship 
to  its  immediate  environment,  let  us  first  ask  ourselves  what  signi- 
ficance, if  any,  is  presented  by  the  great  variations  in  Size  of  the 
different  nerve  cells  :  is  it  but  an  accident  of  their  position  in  the 
cortex  as  to  relative  depth  :  is  it  indicative  merely  of  the  cuje  of  the 
cell  :  is  it  dependent  on  their  specific  functional  connections :  or  upon 
the  degree  of  complexity  attained  by  the  nerve  element  1  Is  it  a  mere 
"  accident "  of  their  position  ?  This  has  been  assumed  by  Meynert 
upon  premises  which  cannot  for  one  moment  be  admitted.  In  an  article 
published  some  ten  years  since,*  Meynert  summarily  dismisses  the 
observations  of  Betz  on  the  "giant  cells"  of  the  anterior  central 
convolution  ("  ascending  frontal ")  as  of  no  importance,  because  the 
explanation  of  their  huge  size  is  solely  due,  according  to  Professor 
Meynert,  to  the  greater  depth  of  the  cortex  of  this  convolution ;  the 
apex  processes  of  these  cells,  therefore,  having  to  traverse  a  greater 
distance  in  their  low-lying  groups  ere  they  reach  the  outer  layer  of 
the  cortex.  Their  groupings,  also,  he  explains  as  a  mere  pressing 
together  of  the  cells  by  the  bundles  of  nerve  fibres  passing  upwards 
from  the  medulla  of  the  gyrus.  It  is  unfortunate  that  the  great 
Vienna  histologist  should  lend  the  weight  of  his  authority  to  so 
utterly  untenable  a  position.  It  is  obviously  natural  to  suppose  that 
the  greater  the  distance  along  which  a  nerve  cell  has  to  transmit  its 
energy,  the  lax'ger  will  that  nerve  cell  probably  be ;  in  the  next  place, 
as  we  are  dealing  with  the  non-mechdl ated  fibre  of  the  apex,  we  might 
also  assume  that  the  loss  by  difiusion  around  nuiy  also  demand  a 
comparatively  stronger  discharge  in  such  a  case,  and  hence  a  pro- 
portionately larger  cell :  all  this  is,  of  course,  in  accordance  with 
Meynei't's  assumption.  Moreover,  that  the  pyramidal  cells  steadily 
increase  in  dimensions  with  their  depth  is  also  in  favour  of  his 
position,  were  it  invariably  true;  but  this  is  not  the  case.  It  has 
been  shown  in  our  examination  of  the  brain-cortex  in  man  and  in 
mammals,  that  alongside  the  largest  pyramidal  cells  are  numbers  of 
others  of  the  smallest  dimensions,  which,  according  to  Meynert's  view, 
should  be  much  larger  than  the  superimposed  elements.  Even  in  the 
woodcut  illustrative  of  the  five-laminated  cortex  given  in  Meynert's 
original  memoir,t  we  find  numerous  exceptions  to  his  rule,  that  the 
smaller  element  is  always  higher  in  the  cortex,  and,  given  a  section 

*  Psi/chiairi.9ch('s  Centrcdhlatt,  No.  6,  1878. 
+  "  The  Brain  of  Mammals,"  Syd.  Soc.  Trans. 


SIGNIFICANCE    OF    CELL-GROUPINGS.  107 

of  brain  examined  by  the  fresh  methods,  such  exceptions  become  very 
nnmerous  indeed.  That  the  general  tendency  to  this  larger  size  with 
tlieir  deeper  position  is  maintained,  we  of  course  allow;  what  we 
dis^iiite  is  the  explanation  afforded,  which  leaves  out  of  consideration 
the  numerous  exceptional  small  elements  referred  to. 

In  the  next  place,  were  this  explanation  held  tenable  for  this  form 
of  cortex,  the  formation  described  by  us  as  the  modified  loweP 
limbic  cortex  of  the  rodent  woiild  entirely  confute  such  a  principle, 
since  here  we  have  a  series  of  very  larg'e  cells,  the  largest  by  far 
in  the  whole  depth,  here  lying  quite  superficial  as  the  second  layer 
of  the  cortex. 

What  then  is  the  more  probable  explanation  of  this  increase  in  size 
of  the  cell  ?  If  we  carefully  note  a  section  of  fresh  bi-ain,  we  find  that 
although  the  majority  of  the  pyramidal  cells  steadily  enlarge  at 
greater  depths — the  ganglionic  cell-clusters,  but  a  very  short  remove 
from  the  largest  pyramidal  cells,  represent  an  enormous  leap  in 
dimensions.  Plates  i.  and  ii.  represent  conclusively  what  we  have 
here  stated  :  the  outlines  of  the  cells  are  represented  at  their  re- 
spective levels  as  sketched  by  the  camera  lucida,  and  it  is  seen  that 
the  upper  elements  measure  but  18  <«.  x  11  /x,  being  quite  superficial 
in  the  series  of  small  pyramids  :  that  the  lowest  of  the  series  include 
elements  measuring  but  36  /a  x  23  /a,  although  at  a  depth  of  1116  /i 
beneath  the  former  :  whilst  a  little  higher  we  find  numerous  cells 
measuring  18 /^  x  13;«-  in  size — i.e.,  very  slightly  larger  than  those  of 
the  superficial  series,  although  953  /a  beneath  them.  When,  however, 
we  pass  from  the  largest  pyramidal  to  the  ganglionic  cells  lying  only 
209  ijj  lower  down,  we  come  suddenly  upon  huge  elements  measui-ing- 
from  84  /i  to  97  /*  in  length,  by  36  (m  to  46  [m  in  breadth.  The  increase 
in  dimensions,  therefore,  is  so  sudden  as  to  be  out  of  all  proportion 
to  the  greater  depth  of  this  layer.  Is  there,  then,  no  constant  re- 
lation between  the  size  of  the  cell  and  other  conditions  to  which  it  is 
exposed,  which  may  give  us  the  required  explanation  1 

This  we  believe  to  be  the  case:  we  find  as  a  constant  accompaniment 
of  increasing  bulk,  much  more  complex  relationships  with  surrounding 
cell-districts — in  other  words,  the  larger  the  cell,  the  greater  the  number 
of  its  branches.  But  the  older  the  nerve  cell,  the  longer  time  has  it 
had  for  the  establishment  of  organised  relationships  around  ;  and  hence 
it  follows  that  the  older  cell  is  also  the  larger  element.  In  fact,  it 
appears  to  us  that  the  size  of  the  nerve  Cell  is  chiefly  dependent 

upon  its  ag'e  and  the  multiplicity  of  its  surrounding"  connections. 

There  is,  however,  another  factor  which  must  be  allowed  much  weight 
in  the  case  of  the  motor  cortex.  The  medullated  fibre  (axis-cylinder 
process),  which  arises  from   the   basal   extremity  of  the  great  motor 


108 


THE    CORTEX    CEREBRI    IX    MAN, 


cells,  traverses  uninterruptedly  an  enormous  distance  to  reach  the 
respective  cell-groups  which  rei)reseut  in  the  spinal  cord  the  muscu- 
lature of  the  limbs.  The  distance  traversed  is  very  unequal  between 
the  lumbar  and  cervical  groups ;  the  cortical  centres  representing  the 
lower  extremities  having  not  only  a  greater  distance  through  which 
to  discharge  their  energy,  but  a  far  more  massive  musculature  to  call 
into  activity,  than  is  the  case  with  the  arm-centres  of  the  cortex. 
Again,  the  cortical  centres  for  the  upper  extremities  not  only  act 
through  a  greater  range,  but  they  innervate  larger  groups  of  muscles 
than  do  the  centres  for  the  head  and  neck,  the  muscles  of  articulation, 
deglutition,  &,c.  It  would,  therefore,  be  natural  to  presume  that  the 
cortical  cell  groups  representing  these  respective  regions  would  differ 
considerably  in  the  size  of  their  individual  elements.  The  histology 
of  the  motor  area  fully  warrants  us  in  stating  this  to  be  the  case  : 
the  smallest  cells  being  found  at  the  lower  end  of  the  central  gyri  and 
Broca's  convolution — and  thence  increasing  rapidly  in  size  upwards 
towards  the  centres  for  the  great  musculature  of  the  limbs,  as  illus- 
trated by  the  following  table  of  actual  measurements  : — 


Comparative  Size  of  Braix  Cells. 


AvF.RAOE  Size  of 
Gakgliun  Cells. 

Largest  Cell — 
Maximum  Sizb. 

Left  ascending  frontal  (upper  end),     . 

60  M  X  25  /x 

90  m   X  45  m 

Frontal  gyri  (areas  at  posterior  end), 

45  m  X  20  M 

69  M  X  27  /i 

Left  ascending  frontal  (lower  end),      . 

35  M  X  17  M 

41  M  X   18  m 

Left  ascending  parietal  (upper  end),  . 

66  M  X  41  ju 

88  M  X  41  M 

,,               ,,              (nuddle  third), 

46  M  X  37  fx 

55  M  X  32  M 

,,               ,,               (lower  third), 

41  /x  X  24  ,x 

... 

We  find  this  law  fully  borne  out  by  the  results  of  an  examination 
of  the  bulbar  and  spinal  cell  groups  in  different  regions — the  g"reat9P 
musculature  being  presided  over  by  the  groups  of  laPgest  CellS. 
We,  therefore,  see  reason  for  regarding  the  dimensions  of  these  cells  in 
the  cortex  as  influenced  by — 

(1)  Range  of  discharging  distance. 
(2)  Size  of  musculature  innervated.  (3)  Age  of  nerve  cell. 

(4)  Resulting  multiplicity  of  cell  connections. 

It  will  be  seen  from  these  conclusions  that  the  deopsst  elements 
are  not  necessarily  the  oldest,  for  some  of  the  lowest  of  a  series  are 


THE    NUCLEUS    OF    THE    NERVE    CELL.  109 

very  small  and  very  simple  in  their  connections — the  reason  for  this 
was  shrewdly  given  by  Dr.  Ross  from  observations  on  the  develop- 
ment of  the  motor  cell  groups  in  the  anterior  cornu  of  the  spinal  cord.* 
His  statement  is  to  the  effect  that  the  younger  cells  are  in  close  con- 
tiguity to  the  blood-vessels  :  that  as  growth  proceeds,  they  are  thrust 
further  aside,  so  that  the  larger  and  older  cells  lie  midway  between 
parallel  vessels.  No  one  familiar  with  the  structure  and  disposition  of 
the  cortical  elements  of  the  bi'ain  will  fail  to  see  the  force  of  this  sugges- 
tion. These  small  pyramidal  elements  which  we  meet  with  constantly 
side  by  side  with  the  older  cells,  are  found  often  with  very  few  lateral 
branchings,  and  the  apex-process  thins  out  rapidly  and  is  lost  to  view 
at  a  short  distance  from  the  cell,  notably  contrasting  in  this  respect 
with  the  older  elements,  whose  apex-process  can  be  traced  up  into  the 
first  layer  or  peripheral  zone.  It  is  important  to  note  this  fact — new 
elements  are  being  continually  formed,  which  for  some  time  have  no 
connection  with  the  grey  meshworh  of  the  outer  zone  of  the  cortex. 
These  extensions  from  the  apex  or  centric  pole  of  these  young  cells 
continue  to  thrust  themselves  further  outwards,  meanwhile  forming 
lateral  connections  by  delicate  offshoots,  with  nerve-fibre  plexuses 
around. 

Can  we  suggest  the  significance  borne  by  the  nucleus  in  the 
autonomy  of  the  nerve  cell? — The  results  of  physiological  experimenta- 
tion by  Ferrier,  Hitzig,  Horsley,  and  Beevor,  and  clinical  investiga- 
tions, especially  those  of  Hughlings- Jackson,  appear  conclusively  to 
indicate  the  anterior  or  fronto-parietal  realms  of  the  cerebrum  as 
especially  motor ;  and  the  occipital  and  temporo-sphenoidal  lobes  as 
especially  sensory,  in  their  endowments ;  and  it  is,  to  say  the  least, 
highly  suggestive  that  the  large  pyramidal  and  ganglionic  cells 
peculiarly  characterise  the  former,  just  as  the  smaller  elements  and 
densely  aggregated  granule  cells  characterise  the  latter — that,  in  fact, 
as  we  pass  from  motor  to  sensory  realms,  so  we  find  the  nerve  cells 
progressively  diminishing  in  bulk  and  the  granule  cell  progressively 
pi'eponderating  in  number.  Dr.  Hughlings-Jackson  long  since  sug- 
gested the  representation  of  small  muscles  by  small  cells,  requiring  as 
they  would,  in  their  almost  ceaseless  lively  activity,  rapid  and  frequent, 
though  short,  discharges  of  energy  ;  in  fact,  he  regards  such  small 
elements  as  necessarily  of  unstable  equilibi'ium.  His  words  are  as 
follows  : — 

"  I  have  suggested  that  the  size  and  shape  of  cells,  as  well  as  their  nearness  to 
the  tumour,  or  other  source  of  irritation,  will  have  to  do  with  their  becoming 
unstable  ;  other  things  equal,  the  same  quantity  of  matter  in  many  small  cells  will 
present  a  vastly  greater  surface  to  the  contact  of  nutrient  material  than  the  same 

*  Diseases  of  the  Nervous  System,  vol.  ii.,  p.  26,  ISSl. 


110  TlIK    CORTKX    CEHEUHI    1\    MAN. 

quantity  in  one  large  cell.  I  have  also  susfgested  that  small  muscles,  or,  more 
properly,  movements  which  require  little  energy  for  the  displacements  they  have 
to  etlect  (tliose  of  the  face  and  of  the  hands  in  touch,  for  example),  are  represented 
by  small  cells.  Such  movements  are  rapidly  changing  during  many  of  tiie 
operations  they  serve  in — writing,  for  example — and  require  repetitions  of  short 
liberations  of  energy,  and  necessitate  quick  recuperation  of  tlie  cells  concerned. 
Movements  of  the  upper  arm  are,  in  comparison,  little  changing,  and  require 
persistent  steady  liberation  of  energy."  * 

When,  however,  we  consider  the  assumed  sensory  element  of  the 
cortex — the  minute  angular  and  granule  cells — we  must  not  lose  sight 
of  a  remarkable  distinction  between  them  and  the  assumed  motor 
unit,  and  that  is,  the  great  proportionate  preponderance  of  the  nucleus 
to  the  cell  itself  in  the  former.  That  the  nucleus  does  exert  souie 
mysterious  influence  over  the  nutritive  and  functional  activity 
of  the  cell  has  long  been  surmised  ;  and  the  results  of  our  histological 
inquiry  indicate  that  nuclear  degeneration  within  the  nerve  cell  is 
peculiarly  associated  with  certain  states  of  mental  and  motorial  in- 
stability. We  have  long  been  accustomed  to  regard  it  as  related  more 
definitely  to  the  functional  activity  of  the  cell,  and  less  direclly 
related  to  the  nutritive  activity  of  the  cell.  In  other  words,  the 
cell  is  subject  to  a  constant  supply  of  nutritive  plasma — it  gradually 
assumes  a  state  of  nutritive  instability,  and  will  necessarily  discharge 
its  accumulated  energy  in  accordance  with  the  simple  law  of  nutri- 
tive rhythm — the  resulting  stable  equilibrium  is  succeeded  by  a 
measurable  period  ere  the  potential  energising  of  the  cell  has  once 
more  brought  it  up  to  its  former  state  of  instability.     Were  this  all 

that  occurs,  the  process   of  storag"e  and  liberation  of  energ'y 

would  be  a  simpler  rhythmic  process  than  the  more  compounded 
rhythm  which  actually  pertains  to  mental  operations. 

If,  however,  we  regard  the  nucleus  as  affecting  the  functional  activity 
of  the  cell,  as,  in  fact,  restraining  or  inhibiting"  its  discharg-e,  as  a 
kind  of  imperium  in  imperio  exercising  a  controlling  influence  upon  the 
perturbations  which  reach  the  cell  from  sensory  surfaces  :  then  the 
presence  of  a  healthy  nucleus  would  become  an  all-important  feature 
in  the  cell-life — a  feature  of  the  utmost  significance  to  us  in  our  patho- 
logical enquiries.  What  really  does  occur  when  these  nuclei  are 
especially  affected  by  morbid  processes,  we  shall  refer  to  more  particu- 
larly in  our  chapter  on  the  epileptic  neuroses.  The  view  we  have  here 
taken  of  the  significance  of  the  nucleus  would  lead  to  the  conclusion 
that  when,  from  its  degeneration  or  morbid  state,  it  fails  to  inhibit  the 
cell,  these  nerve  elements  would  be  subject  to  a  rapid  runniny-doivn 

*  "  On  Temporary  Paralysis  after  Epileptiform  and  Epileptic  Seizures,"  Brain, 
vol.  iii. ,  footnote  to  p.  43G. 


EXCITABILITY    OF    CORTEX.  Ill 

on  trivial  excitation,  and  in  servile  obedience  to  the  law  of  nutritional 
rhythm  ;  in  fact,  we  should  here  find  an  explanation  of  morbid  insta- 
bility such  as,  e.g.,  in  motor  realms  results  in  convulsive  states,  and  in 
the  substrata  of  mental  operations  in  varied  psychical  states  and 
reductions  in  consciousness. 

It  is  these  considerations  which  induce  us  to  regard  the  dispropor- 
tionately large  nucleus  of  these  small  angular  elements  of  the  second 
layer  of  the  cortex  as  being  of  some  significance.  Subject  as  such 
minute  cells  are  to  a  rapid  accumulation  of  energy,  we  might  presume 
that  some  restraint  must  be  established  to  prevent  their  reckless 
liberation  of  energy,  and,  hence,  we  believe  such  restraining  capacity 
to  be  afi'orded  by  the  very  large  nucleus.  In  the  next  place,  we 
have  every  reason  for  believing  that  this  superficial  belt  of  angular 
cells  is  in  direct  organic  connection  with  the  subjacent  cells  of  large 
size,  and  that  their  morbid  instability  would,  therefore,  aff"ect  these 
larger  units,  which,  from  the  small  size  of  their  nucleus,  would  be  more 
subject  to  the  law  of  nutritional  rhythm  in  their  discharge  of  energy. 
As  indicated  by  Dr.  Ross,  and  also  in  the  preceding  note  by  Dr. 
Hughlings- Jackson,  the  large  cell  would  present  a  far  smaller  area 
in  contact  with  nutrient  material  than  the  same  amount  of  protoplasm 
broken  up  into  numerous  minute  elements;  and  hence,  such  large  cells 
would  labour  under  nutritive  disadvantages — would  be  reservoirs  for 
the  slow  accumulation  and  storage  of  energy,  which,  when  liberated, 
would  again  result  in  a  tardy  reinstatement  of  nutritive  instability. 

Electrical  Excitability  of  the  Cortex.— Fritsch  and  Hitzig  were 

the  first  to  demonstrate,  in  the  year  1870,  the  excitability  of  the  cortex 
in  animals  to  the  galvanic  current;  and  three  years  later  Prof.  Ferrier 
prosecuted  with  the  faradaic  current  his  first  investigations  into  the 
functions  of  the  cerebral  hemispheres.  The  method  of  stimulation 
employed  by  Ferrier  was,  to  use  his  own  description,  "The  application 
of  the  electrodes  of  the  secondary  spiral  of  Du  Bois-Reymond's  induc- 
tion coil,  connected  with  a  cell  of  the  mean  electro-motive  power  of 
one  Daniell.  The  resistance  in  the  primary  coil  was  such  as  to  give 
a  maximum  current  of  1-9  absolute  unit,  as  estimated  for  me  by 
my  colleague,  Professor  Adams.  The  induced  current  generated  in 
the  secondary  coil  at  8  cm.  distance  from  the  primary  spiral  was  of  a 
strength  sufiicient  to  cause  a  pungent,  but  quite  bearable,  sensation 
when  the  electrodes  were  placed  on  the  tip  of  the  tongue."  *  We  can 
but  briefly  summarise  here  some  of  the  more  important  facts  elicited 
by  these  experimental  methods  respecting  the  reaction  of  the  cortex  to 
electric  stimuli. 

Latent  Period  of  Stimulation  and  Summation  of  Stimuli. 

*  Functions  of  the  Brain,  2ud  Edit. ,  p.  223. 


112  THE   CORTEX    CERp:i5Kl    IN    MAN. 

— It  is  from  these  phenomena  we  infer  that  tlie  cortical  areas  found  to 
be  excitable  are  really  centres,  in  the  proper  acceptation  of  tlx-  tcim. 
It  must  be  remembered  that  a  ganglionic  centrum  is  an  elabOFEtive 
structure,  and  that  stimuli  api)lied  to  it  meet  with  delay  ere  the  result- 
iu^'  response  be  elicited.  The  excitation  of  a  centre  is  therefore  accom- 
panied by  the  time  element  seen  in  nerve  stimulation  in  a  marked 
degree,  and  this  is  very  appreciable  in  the  stimulation  of  the  so-called 
psychO-motOP  centres  of  the  cortex.  This  is  well  brought  out  on 
contrasting  the  effects  of  a  carefully-regulated  current  applied  to  the 
cortex  of  this  realm,  with  the  effects  of  the  same  current  as  applied 
to  the  medullated  strands  immediately  beneath,  by  first  excising  the 
overlying  cortex.  In  the  first  place,  we  find  (after,  of  course,  abstracting 
the  time  requiied  for  transmission  down  spinal  cord  and  motor  nerves 
and  the  latent  pei'iod  of  the  muscle)  that  the  retardation  is  0045  of 
a  second,  and  in  the  latter  place,  0  03  of  a  second  {Franck  and  I'ilres). 
So,  also,  if  very  feeble  stimuli  be  applied  to  the  cortical  centres  their 
summation  occurs,  so  that  no  contraction  takes  place  until  several 
stimuli  have  been  delivered.  Of  the  many  interesting  facts  revealed 
by  the  researches  of  Schafer  and  Horsley,  Franck  and  Pitres,  relative 
to  the  eflTect  of  electric  stimuli  on  motor  centres,  the  moi'e  important 
may  be  stated  as  follows  : — 

(1)  In  the  savie  animal  tlie  number  Of  Stimuli  per  second  requisite 
to  produce  a  continuous  contraction  is  always  the  same  for  cortex, 
motor  nerve,  and  muscle. 

(2)  A  continuous  contraction  does  not  occur  on  stimulating  a 
motor  centre,  until  the  rate  of  stimuli  reaches  4G  per  second ;  below 
this,  single  contraction  occurs  for  each  shock  or  thereabouts. 

(3)  The  contractile  rhythm  of  muscle,  whether  it  be  cortex, 
corona  radiata,  or  spinal  cord  that  is  stimulated,  has  been  shown  to 
follow  this  rule  : — 

Rhythm  of  stimulus  below  10  per  second  =  muscular  rhythm 

identical. 
Rhythm  of  stimulus  at  above  10  per  second  =  muscular  rhythm 

constant  and  independent  {Schafer  and  Horsley). 
Rhythm  of  stimulus  about  4G  per  second  =  continuous  muscular 

contraction  {Franck  and  Fitres). 

(4)  The  muscular  curve  of  cortical  stimulation  is  less  sudden  in 
its  rise  and  more  sustained  than  the  curve  shown  in  subcortical 
stimulation,  and  all  voluntary  muscular  contractions  show  a  similar 
rate  of  iindulation  in  the  muscular  curve. 

Modifying"  Circumstances. — The  excitability  of  the  cortical  areas 
is    subject  to  great   variation.     Thus,    different   animals   vary  in   the 


FUNCTIONAL    EQUIVALENCE.  115 

intensity  of  stimulus  required  to  produce  the  adaptive  movement; 
and  the  same  animal  will  vary  from  time  to  time  as  regards  this 
susceptibility,  according  to  the  conditions  in  which  it  is  placed. 
Severe  hsemorrhag'e  greatly  reduces  or  even  abolishes,  whilst 
moderate  loss  of  blood  exalts,  the  excitability  of  these  parts 
{.\hink,  IJitzig).  Prolonged  expOSUre  and  Stimulation  rapidly 
exhaust,  whilst  apnoea,  and  the  deep  narcOSiS  of  chloroform, 
ether,  chloral,  and  morphia  abolish  it  (Schif),  so  that  all  animals 
completely  anjesthetised  fail  to  reveal  such  excitability.  So  if  the 
cortex  be  in  a  state  of  inflammatory  irritation,  its  excitability 
can  be  readily  aroused  by  even  mechanical  stimuli,  which  in  health 
have  no  such  effect.  In  new-born  puppies,  Soltmann  obtained  early 
response  to  stimulus  of  the  corona  radiata,  whilst  it  was  not  until  the 
te7ith  day  that  he  was  able  to  obtain  such  response  by  stimulation 
of  the  motor  cortex. 

Functional  Equivalence. — Some  authorities  have  inclined  to  the 
belief  that  a  process  of  functional  compensation  occurs  when 
injury,  disease,  or  experiment  has  removed  a  motor  centre  :  that  either 
the  opposite  sound  hemisphere,  or  even  some  other  portion  of  the  same 
hemisphere,  may  assume  the  functions  of  the  area  destroyed.  It  is 
undoubtedly  true  that  centres  bilaterally  associated  and  least  inde- 
pendent recover  soonest  from  a  lesion  of  one  centre,  and  are  least 
affected  in  the  issue,  as  is  indicated  in  the  history  of  all  cases  of 
ordinary  hemiplegia;  but  this  can  scarcely  explain  what  we  meet 
with  in  experiments  on  dogs.  Here  it  has  been  shown  that  if  the 
motor  centres  of  one  hemisphere  be  destroyed,  the  resulting  hemiplegia 
is  soon  recovered  from,  and  if  this  were  due  to  the  substitutional 
activity  of  the  other  hemisphere,  ablation  of  the  centres  in  the  latter 
would  presumably  paralyse  both  sides.  This,  howevei',  is  not  the 
case ;  for,  as  Carville  and  Duret  clearly  proved,  the  reinstated  power 
of  the  limb  first  paralysed  is  not  affected  by  the  second  operation. 
The  explanation  is,  therefore,  not  one  of  functional  substitution  by 
another  region,  but  is  really  due  to  the  more  automatic  character 
of  the  movements  in  these  animals ;  in  other  words,  these  movements 
are  far  more  dependent  upon  the  activity  of  lower  centres  and  are  less 
represented  in  psycho-motor  or  cortical  realms.  In  man  and  the 
monkey  such  movements  are  brought  more  under  the  control  of  the 
volitional  centres— they  are  removed,  as  it  were,  to  a  higher  plane  of 
activity,  are  less  automatic,  more  independent,  and  their  removal  by 
disease  or  injury  is  followed  by  absolute  paralysis  of  the  opposite 
members. 

Phenomena  of  Electric  Stimulation  of  Cortex.— Professor 

Ferrier  ^ives  preference  to  the  faradic   stimulation  of  the  cortex, 

a  1  g 


114  TlIK    COUTKX    CICKICUUI    IN    MAN. 

rjitlier  tliiiu  tin-  galvunic,  .since  tlie  first  requisite  is  a  stimulus  of  a 
certain  duration,  and  not  the  momentary  eilect  of  the  opening  and 
closing  of  a  galvanic  circuit ;  the  latter  also  has  the  further  objection 
of  inducing  electrolytic  decomposition  of  the  brain-surface  if  its  action 
be  long  sustained.  If  the  intensity  of  current  be  greater  than  necessary, 
diffused  stimulation  occurs,  so  that  neighbouring  areas  are  aroused 
into  consentaneous  activity. 

Extra  polar  conduction  has  also  been  proved  to  occur  by  Carville 
and  Duret,  as  seen  in  contractions  of  a  frog's  gastrocnemius,  the  sciatic 
nerve  of  which  rested  on  the  occiput  of  a  brain,  the  motor  area  of 
which  was  stimulated.  This  fact,  however,  does  not  vitiate  the  results 
of  a  minimum  current  applied  to  the  motor  cortex. 

Conduction  to  lower  centres,  as  the  basal  ganglia,  has  been  by 
some  assumed  to  be  explanatory  of  the  results  of  stimulation  of  this 
motor  area.  This  argument  is,  however,  wholly  disposed  of  by  the 
fact  that  (1)  direct  stimulation  of  these  ganglia  (corpora  striata)  results 
in  entirely  different  movements,  not  the  adaptive,  purposive  movements 
which  the  psycho-motor  centres  elicit;  and  that  (2)  when  we  bring  the 
electrodes  upon  their  immediate  superficial  aspect,  at  the  insula,  no 
response  whatever  occurs.  As  might  have  been  surmised,  the  radiations 
of  the  coronal  medulla,  entering  into  connection  with  the  motor  cortex, 
are  in  like  manner  functionally  differentiated ;  and,  as  shown  by 
Burdon-Sanderson,  when  the  cortex  is  removed  and  they  are  stimulated, 
similar  purposive  movements  can  be  called  forth. 

Proximity  of  Psycho-Motor  Centres. — It  has  been  seen  that 

the  so-called  motor  cortex,  distinguished  by  the  nested  cell-g"rOUps 
of  the  fourth  layer,  is  so  distiibuted  as  to  occupj^  distinct  areas, 
separated  only  by  narrow  intervals  from  each  other.  This  fully 
accords  with  the  fact  that  the  phenomena  of  electric  stimulation  of 
the  cortex  demonstrate  the  clOSe  proximity  of  wholly  distinct 
centres,  as  Pi-ofessor  Ferrier  remarks—"  Areas  in  close  proximity  to 
each  other,  separated  by  a  few  millimetres  or  less,  react  to  the  electric 
current  in  a  totally  different  manner."  * 

*  Loc.  cit.,  p.  229. 


PART    II.— CLINICAL    SECTION. 

General  Contents.— States  of  Depression  —  States  of  Exaltation  — Fulminating 
Psyclioses— States  of  Mental  Eufeeblement— Recurrent  Insanity— Epileptic 
Insanity— General  Paralysis  of  the  Insane— Alcoholic  Insanity— Insanity  at 
the  Periods  of  Puberty  and  Adolescence- At  the  Puerperal  Period— At  the 
Climacteric  Epoch — Senile  Insanity. 


STATES    OF    DEPRESSION. 

Contents.- Mental  Depression  Defined— Decline  of  Object-Consciousness— Pase  of 
Subject-Consciousness— Muscular  Element  of  Thought- Failure  in  the  Rela- 
tional Element  of  Mind— Sense  of  Environmental  Resistance— Reductions  to 
Automatic  Levels- Sense  of  Effort— Restricted  Volition— Enfeebled  Repre- 
sentativeness—Transformations of  Identity— The  Physiological  Aspect— Defec- 
tive Circulation— Nutritional  Impairment— Explosive  Neuroses— Hunger  of  the 
Brain -Cell— Painful  and  Pleasurable  Mental  States— Reaction-Time  in  Melan- 
cholia—Degrees of  Mental  Depression— Clinical  Varieties  of  Melancholia- 
Simple  Melancholia— Delusional  Melancholia— Hypochondriacal  Melancholia- 
Melancholia  Agitans— States  of  Mental  Stupor— Stupor  and  Hypnotism— Acute 
Dementia. 

Painful  mental  states  are  of  course  normal  under  certain  conditions 
in  health  and  sanity.  As  in  the  intellectual  sphere  it  is  but  human 
to  err,  so  in  the  emotional  sphere  it  is  but  human  to  suffer,  and 
to  feel  acutely  :  hence  it  is  not  the  intensity  of  mental  pain  (although 
this  is  often  far  greater  than  in  healthy  states  similarly  aroused)  that 
characterises  this  phase  of  disease,  for  if  the  anguish  be  the  outcome  of 
commensurately  painful  circumstances,  we  regard  it  as  but  a  natural 
reaction.  It  is  in  the  fact  that  the  emotional  storm  is  out  of  all 
proportion  to  any  exciting  cause,  that  we  recognise  the  departure  from 
the  standard  of  health.  It  is  essential,  therefore,  that  we  carefully  in- 
quire into  the  antecedent  circumstances  of  our  patient's  disorder,  so  as  to 
determine  whether  there  are  adequate  causes  to  account  for  the  distress 
apparent — if  so,  there  is  but  normal  physiological  reaction,  and  cerebral 
function  cannot  be  regarded  as  deranged.  If,  however,  the  mental 
pain  is  the  result  of  trivial  exciting  agencies,  if  moral  or  physical 
agencies  arouse  emotional  states  out  of  all  proportion  to  what  would 
occur  in  the  healthy  mind,  then  we  infer  that  the  grey  cortex  of  the 
brail!  is  so  far  disordered  as  to  functionate  abnormally,  and  we  speak 
of  the  result  as  pathological  depression.  It  is  clear,  therefore,  that  our 
chief  difficulty  in  distinguishing  normal  from  abnormal  states  of 
depression  depends  on  our  correct  estimate  of  the  correspondence 
of  emotional  states  and  their  excitants,  due  allowance  being  made  for 


116  STATES    OF    DEPRESSION. 

special  ppcuHaritios  of  tonipcramcnt.  We  cannot  apply  the  same  rule 
to  a  callous,  nncinotional  nature  as  to  one  refined  and  sensitive. 

In  our  search  for  adequate  causes  we  do  not  confine  our  attention 
to  the  patient's  environment ;  we  must  look  for  possible  moral  agencies, 
such  as  shock,  disappointment,  domestic  affliction,  together  with 
physical  agencies,  such  as  injury,  disease,  privation,  or,  again,  overstrain 
of  mind  or  vicious  habits  of  life — in  all  alike,  the  real  causes  are 
centric,  and  consist  in  a  disordered  function — the  incapacity  of  reacting 
commensurately  in  the  conditions  in  which  the  organism  is  placed — 
in  physiological  terms  it  is  a  "disproportionately  excessive"  reaction. 
"  The  melancholia  which  precedes  insanity  is  distinguished  from  the 
mental  pain  experienced  by  healthy  persons  by  its  excessive  degree, 
by  its  more  than  ordinary  protraction,  by  its  becoming  more  and  more 
independent  of  external  influence,  and  by  the  other  accessory  affections 
which  accompany  it "  (^Griesinger)*  By  one  thoughtful  writer  it  has 
been  suggested  that  melancholia  might  be  spoken  of  as  a  homologous, 
while  mania  and  monomania  might  be  termed  heterologous  affections.! 
This,  of  course,  would  imply  a  quantitative  and  qualitative  distinction ; 
but,  since  emotional  and  intellectual  states  may  be  disordered  quali- 
tatively as  Avell  as  quantitatively,  the  parallel  is  scarcely  applicable. 
Emotional  disturbances  as  the  result  of  disease  differ  from  the  normal 
reactions  of  health,  not  only  in  volume  but  also  in  nature :  as  Herbert 
Spencer  indicates,  the  correspondence  may  vary  in  two  directions, 
quantitatively  and  qualitatively,  in  degree  as  well  as  in  kind. 

With  respect  to  the  non-relational  feelings — the  appetites,  pains, 
&c. — Herbert  Spencer  says  : — "  Their  great  indefiniteness  of  limitation 
and  accompanying  want  of  cohesion  forbid  unions  of  them,  either 
simultaneous  or  successive.  Obviously,  the  emotions  are  characterised 
by  a  like  want  of  combining  power.  A  confused  and  changing  chaos 
is  produced  by  any  of  them  which  coexist."  |  This  very  want  of 
relativity,  this  dissociability  and  absence  of  a  tendency  to  form  strong 
coherent  groups,  at  once  account  for  the  comparative  difficulty  of 
estimating  the  degree  of  mental  alienation  in  melancholia,  as  contrasted 
with  states  of  delusion,  where  we  are  dealing  with  definitely  measurable 
factors. 

Simple  pathological  depression  is  ushered  in  by  that  failure  in 
object-consciousness  which  invariably  inaugurates  a  corresponding 
rise  in  subject-consciousness ;  and  which,  we  have  reason  to  infer, 
implies  a  diminished  functional  activity  in  those  realms  of  the  cerebrum 
correlated  thereto.     The  patient  exhibits  a  growing  indifference  to  his 

*  Mental  Disrates,  p.  210, 

t  Piojc/iohgical  Medicine,  Bucknill  &  Tuke,  3rd  edit.,  p.  440. 

t  Principles  of  Psychology,  vol.  i.,  p.  177. 


ORIECT-    AND    SUBJECT-CONSCIOUSNESS.  117 

former  pursuits  and  pleasures  :  the  ordinary  duties  of  life  and  business 
become  irksome  and  devoid  of  interest :  especially  do  all  forms  of 
mental  exertion  cause  ennui  and  distaste — the  attention  cannot  as 
formerly  be  directed  without  undue  effort,  and  so  reading  becomes 
laborious  and  thought  sluggish  and  monotonous.  The  environment 
fails  to  call  up  pleasurable  associations — a  dreariness  and  gloom 
pervade  the  outside  world,  since  it  is  interpreted  in  terms  of  the 
predominant  feeling.  All  aspects  of  object-consciousness  alike  indi- 
cate the  neg"ative  state.  There  is  a  want  of  vigour  in  the 
representation  of  the  environment,  and  feelings  aroused  thereby  are 
at  a  low  ebb. 

Corresponding  to  this  there  is  a  rise  in  SUbject-COnSCiOUSneSS, 
shown  in  the  prevalence  of  painful  mental  states — the  predominance 
of  gloomy  emotions.  This  is  the  positive  aspect  of  the  patient's 
mental  state,  and  this  aspect  is  the  one  which  chiefly  obtrudes  itself 
upon  our  notice.  It  is  characterised  especially  by  an  all-prevailing 
gloom,  varying  in  degree  from  mild  depression  uj)  to  acutely  painful 
mental  states.  The  subject  may  complain  of  vague  anxiety — a  feeling 
of  some  impending  evil — an  indefinite  prevision  of  coming  sorrow, 
which  gives  its  own  colouring  to  objective  existences  :  he  retires  from 
social  converse,  which  but  adds  to  his  irritation  and  mental  distress, 
gives  himself  up  to  introspective  states,  in  which  he  dwells  upon 
the  present  contents  of  his  mind,  broods  over  his  morbid  feelings, 
and  falls  into  long  reveries,  the  subject-matter  of  which  partakes  of 
the  same  gloomy  colouring.  He  is  hyper-sensitive  over  trifles,  irritable 
and  impatient,  or  his  querulous  humour  may  alternate  with  sullen 
silence  and  obstinacy.  Even  in  this  reticence  and  retirement  from 
social  responsibilities,  this  growing  apathy  to  all  around  or  feeling 
amounting  to  dislike  or  direct  hostility,  we  recognise  the  origin  of 
that  subjectivity,  that  egoistic  state  which,  in  more  advanced  affections 
of  the  mind,  conjures  up  delusions  of  encroachment  and  persecution. 

In  every  case  of  mental  depression  we  have  this  duplex  state  to 
study — the  negative  affection  of  object-consciousness,  and  the  positive 
affection  of  subject-consciousness. 

Griesinger  also  asserts  that  forms  of  mental  depression  are  due  to 
states  of  cerebral  irritation  and  mental  excitation;  but  he  apparently 
fails  to  recognise  the  duplex  nature  of  the  phenomena  in  neglecting 
the  distinction  between  the  two  realms  which  comprise  the  totality  of 
consciousness.     Thus  he  says  : — 

"  In  employing  the  term,  '  states  of  mental  depression,'  we  do  not  wish  to  be 
understood  as  implying  that  the  nature  of  these  states  or  conditions  consists  in 
inaction  and  weakness,  or  in  the  sitpprms'ion  of  the  mental  or  cerebral  phenomena 
which  accompany  them.     We  liav-^e  much  more  cause  to  assume  that  very  violent 


118  STATES   OF    DEPRESSION. 

stales  of  irritation  of  the  brain  and  excitation  in  the  mental  processes  are  here  very 
often  the  cause;  but  the  general  result  of  these  (mental  and  cerebral)  processes 
is  depression,  or  a  paii)ful  state  of  mind.  It  is  sufficient  to  recall  the  analogy  to 
physical  pain ;  and  to  those  who  imagine  they  make  things  better  by  substituting 
'cerebral  torpor'  and  'cerebral  irritation'  for  'depression'  and  'exaltation,' 
it  may  fairly  enough  be  objected  that  in  melancholia  there  is  also  a  state  of 
irritation."  * 

Had  he  asserted  that  both  conditions  co-existed,  a  state  of  cerebral 
torpor  in  the  physical  substrata  of  object-COnsciOUSneSS,  and  a  state 
of  cerebral  irritation  in  the  substrata  of  SUbject-COnSClOUSneSS, 
he  would,  we  think,  have  faithfully  recorded  the  morbid  phenomena. 
The  normal  variations  in  these  antithetic  halves  of  consciousness,  with 
which  reverie  and  dreamy  states  render  us  familiar,  have  been  thus 
lucidly  expressed  by  Herbert  Spencer,  when  in  reference  to  the  vivid 
and  faint  aggregates  of  consciousness  he  says  : — 

"  Though  entire  unconsciousness  of  things  around  ui?  is  rarely  if  ever  reached,  yet 
tlie  consciousness  of  them  may  become  very  imperfect ;  and  this  imperfect 
consciousness,  observe,  results  from  the  independence  of  the  faint  series  becoming 
for  the  time  so  marked  that  very  little  of  it  clings  to  the  vivid  series."  t 

Decline  in  Object-consciousness. — The  various  states  of  con- 
sciousness and  the  changes  from  one  to  the  other  constitute  collectively 
the  sole  elements  of  mind ;  and  our  considerations,  therefore,  apply  to 
feelings  and  the  relations  between  feelings.  First,  let  us  note  that  the 
variations  from  the  normal  state  embrace  a  quantitative  and  a  qualita- 
tive change.  Feelings  may  succeed  each  other  in  rapid  order,  or  in 
slow,  monotonous  file ;  they  may  arise  in  serial  order,  or  numbers  of 
disconnected  states  may  simultaneously  thrust  themselves  into  the 
field  of  consciousness,  producing  turmoil  and  indefinite  vague  emotion 
and  thought.  On  the  other  hand,  mental  phenomena  may  exhibit  a 
qualitative  alteration,  such  as,  e.g.,  is  shown  in  degrees  of  intensity  of 
feeling,  or  again,  of  definiteness  as  due  to  the  more  or  less  relational 
character  of  the  product.  The  decline  in  object-consciousness  which 
occurs  in  states  of  pathological  depression,  such  as  we  are  now  dealing 
with,  presents  us  with  the  following  features  : — 

(a.)  Enfeebled  representativeness:  (6.)  a  lessened  seriality  of  thought 
(weakened  attention) :  (c.)  diminution  or  failure  in  the  muscular 
element  of  thought. 

The  last  appears  to  us  so  important  a  factor  in  these  morbid  states, 
as  to  demand  here  somewhat  careful  and  detailed  consideration. 

Failure  in  the  Muscular  Element  of  Thoug-ht.— The  constant 

accompaniment  of   depressed    mental  states  is  an  enfeebled  range  of 

*  "Mental  Diseases,"  Syd.  Sor.,  p.  210. 
t  Principles  of  Psycholor/y,  vol.  ii. ,  p.  459. 


FAILURE    IN    THE    MUSCULAR    ELEMENT    OF    THOUGHT.  119 

perception;  and,  since  every  perception  is  a  complex  phenomenon  of 
coniposite  states  of  consciousness — if  one  or  other  of  the  essential 
elements  of  an  idea  or  of  a  presented  object  be  wanting — the  definite 
realisation  of  such  object  or  idea  is  defective.  The  loss  may  be  in  the 
more  sensuous  element  of  the  perception — in  those  qualities,  in  fact,  of 
body  which  are  categorised  as  dynamic  ("  primordial "),  e.g.,  colour, 
odour,  taste,  or  the  pure  sensations  appreciated  by  the  specialised 
senses  of  sight,  hearing,  taste,  or  smell ;  again,  the  loss  may  pertain 
chiefly  to  the  statical  or  primary  attributes  of  the  perception— 
those  of  size,  position,  form.  A  vigorous  perception  of  these  primary 
or  space  attributes  of  body  is  dependent  largely  ttpon  our  "  sixth  "  or 
muscular  sense.  If,  therefore,  this  sense  undergo  any  diminution, 
so  will  the  space-attributes  of  body  become  less  vividly  conceived— 
the  cognition  is  hut  feebly  produced.  The  sense  of  sight  is  pre-eminently 
interwoven  with  the  muscular  mechanism  involved  in  our  perception 
of  objects :  and,  since  the  retinal  field  can  only  receive  the  impress  of 
these  dynamic  attributes  of  body  by  means  of  a  musculature,  which 
rotates  the  eyeball  and  so  disposes  the  visual  axis  suitably,  the  know- 
ledge of  such  movements,  comprising  figure,  bulk,  and  position  in  space, 
becomes  inextricably  blended  with  these  dynamic  attributes. 

There  is  little  doubt  that  the  retinal  impressions  are,  in  states  of 
melancholic  depression,  but  feebly  produced;  but  whether  the  muscular 
element  of  perception  is  first  or  simultaneously  aflfected,  is  an  enquiry 
of  special  interest.  And  here  we  must  distinguish  between  that  portion 
of  the  muscular  element  which  enters  into  our  higher  intellectual  con- 
cepts, and  that  grosser  factor  of  the  large  musculature  of  the  limbs,  kc, 
which  subserves  the  purpose  of  locomotion  and  coarse  movements.  The 
sense  of  muscular  contractions  which  forms  the  basis  of  the  primordial 
ideas  of  form,  size,  position,  lapses  eventually  in  consciousness  as  a  pure 
sense  of  muscular  contraction.  With  the  larger  musculature  this  is 
not  so :  it  is  essential  that  the  movements  of  the  limbs,  their  con- 
traction, and  tension  should  be  exquisitely  registered  centrally,  as 
thereby  alone  can  we  gain  an  idea  of  their  position  in  space  apart 
from  the  sense  of  sight,  and  appreciate  the  relative  weight  of  objects 
and  the  resistance  ofi'ered  by  them.  The  unrestrained  action  of 
these  muscles  signalises  to  our  minds  the  absence  of  external  resist- 
ance, and  the  rise  in  the  muscular  sense  which  accompanies  any 
resistance  opposed  is  the  direct  measure  of  such  resistance.  Similarly, 
with  the  "  muscularity  of  thOUg"ht,"  which  in  the  normal  state  is 
of  free  and  easy  play,  the  rise  into  consciousness  of  its  primordial 
muscular  element  means  efi'ort,  and  at  once  suggests  to  the  mind 
the  same  notion  of  resistance  in  the  environment.  It  is  obvious, 
we    think,  that    the    muscular   element   is    the    first  to  decline  :    for 


120  STATES    OF    DKl'RESSION. 

cases  of  intense  grief,  as  from  a  sudden  mental  shock,  are  associated 
with  a  notable  contraction  of  this  sphere,  and  space  diinemsions  are 
altered  and  contracted.  This  feature  is  one  of  importance,  since  it 
clearly  points  to  the  decline   of   the  more  relational  elements   of 

the  perceptive  process. 

The  rohitions  of  bulk,  coiitignration,  and  position  are  recognisable  only  by  the 
intellectual  operations  of  the  miud,  and  it  is  this  intellectual  element  which  is 
earliest  enfeebled.  This  follows,  therefore,  the  inverse  order  of  the  evolution 
of  psychical  powers.  Muscular  sense,  which  appears  much  later  in  the  evolution 
of  the  nervous  system  than  do  the  general  or  the  specialised  sensations  of 
sight,  hearing,  &c.,  is  in  morbid  states  the  first  to  succumb.  The  infant  learns 
to  appreciate  the  colour  of  an  object  long  before  he  has  received  the  visual  percep- 
tion of  its  form,  bulk,  and  position  :  he  learns  to  recognise  sounds  ere  the  direction 
whence  they  proceed  establishes  the  organised  series  of  reflected  changes  in  certain 
nuclei  of  the  medulla,  which  enables  him  to  turn  the  head  and  localise  the  source 
of  such  sounds. 

Just  as  in  the  infant  we  trace  the  sensuous  element  of  mind  as 
preceding  in  evolution  the  relational  element,  so,  in  dissolutions  of 
the  nervous  system  in  the  insane,  the  inverse  order  is  followed,  and 
the  relational  decline  before  the  sensuous  or  "  primordial  "  sensations  : 
and,  since  a  relation  can  best  be  defined  as  a  state  of  consciousness 
"  holding  together  other  states  of  consciousness  "  (Herbert  SjJencer),  so 
individual  conscious  states  become  dissociated  or  unrelated.  The  loss 
of  such  relational  element  implies  a  certain  degree  of  intellectual 
torpor ;  but,  as  we  shall  have  reason  to  see,  the  sense  of  volitional 
freedom,  which  is  probably  an  abstract  product  of  the  muscular  sense, 
must  in  like  manner  decline.  Our  vigorous  perception  of  the  outside 
world  depends  largely  upon  vivid  states  of  consciousness :  our  realisa- 
tion of  such  related  states  by  muscular  sense  and  its  derivatives  may 
be  compared  to  a  mental  g'rasp  of  the  environment :  and,  in  direct 
proportion  to  the  vigour  of  such  grasp,  does  our  power  over  the  envi- 
ronment predominate,  and  the  resistance  of  the  latter  diminish.  In 
states  attended  by  decline  of  the  muscular  or  relational  element  of 
mind,  therefore,  external  resistance  must  be  ^?ari  jmssu  intensified,  and 
the  apparent  energy  and  freedom  of  the  will  restricted. 

Let  us  analyse  this  component  of  ideation  more  thoroughly,  and  we 
shall  find  that  not  only  is  every  perception  evolved  from  a  series  of  com- 
plex related  states  of  consciousness,  but  that  every  concrete  perception  or 
idea  is  attended  by  certain  vivid  primaxy  states  of  consciousness  and  other 
secondary  component  impressions  which  fail  to  rise  into  consciousness, 
or  are  more  or  less  revivable  or  i-epresentative.  Now  such  unconscious 
components  of  an  idea  which  we  take,  so  to  speak,  for  granted — these 
lapsed  states  of  consciousness,  although  they  form  an  integral  com- 
ponent of  the  perception  or  ideal  representation,  are  chiefly  of  mus- 


SENSE    OF    ENVIRONMENTAL    RESISTANCE.  121 

CUlaP  OPig"!!!.  If,  in  every  conception  of  a  spliere,  the  roll  of  the 
eyeball  on  its  axis  were  induced,  the  objective  origin  of  the  perception 
of  its  form  would  be  evident  :  but,  although  such  actual  muscular 
movements  do  not  occur,  yet  the  musculatures  productive  of  such 
movements  have  their  centres  innervated  by  each  such  perception. 
Still,  such  innervation  as  a  direct  muscular  state  or  sense  of  muscular 
tension  and  movement  fails,  in  health,  to  rise  into  consciousness — an 
automatic  play  calls  up  vivid  representation  of  form  and  figure  without 
any  consciousness  of  muscular  action  or  strain.  As  before  stated,  the 
frequent  repetitions  of  the  muscular  act  essential  to  the  knowledge  of 
figure,  position,  &c.,  have  eventually  resulted  in  a  lapse  of  the  same 
muscular  action  in  consciousness. 

If,  however,  delaij  occur  in  the  production  of  such  relational  states, 
the  statical  attributes  of  body  will  be  perceived  only  after  COnsCiOUS 
effort ;  even  actual  muscular  movement  and  the  tension  so  brought 
about  for  the  realisation  of  more  vivid  conception  of  form,  configur- 
ation, and  bulk,  will  give  that  sense  of  strange  effort  which  metes 
out  to  us  the  resistance  of  the  environment.  Do  actual  muscular  move- 
ments occur  in  the  deranged  states  with  which  we  are  now  concerned, 
and  does  eonscious  effOPt  thus  arise  upon  planes  which  are  normally 
devoid  of  such  feelings  1  The  melancholic  exhibits  to  a  notable  degree 
the  effort  which  it  causes  him  to  think,  reflect,  or  attend  to  what  is  said, 
or  to  what  he  reads.  It  appears  to  us  that  the  true  explanation  is 
due  to  mental  operations  being  reduced  in  level  so  far  as  to  establish 
conscious  effort  in  lieu  of  the  usual  unconscious  operations,  or  lapsed 
states  of  consciousness  which  accompany  all  intellectual  processes.  The 
restless  movements  of  the  intellectual  eye  (in  the  artist,  poet,  <fec.),  as 
well  as  those  of  the  state  of  maniacal  excitement,  bespeak  in  the  former 
case  the  exalted  muscular  element  of  thought,  and  in  the  latter  a  highly 
reflex  excitability;  but  in  the  melancholic  these  muscles  of  relational 
life  are  usually  at  rest,  the  eye  is  fixed,  dull,  heavy,  sluggish  in  its 
movements  and  painful  in  effort,  the  eyelids  are  drooped,  the  limbs 
motionless.  The  only  muscles  in  a  state  of  tension  are  those  which 
subserve  emotional,  and  not  relational  life,  viz.,  the  small  muscles  of 
expression. 

Hence,  the  failing  vigour  of  representative  states  aroused  in  simple 
perception  or  ideation,  issues  in  the  sentiment  of  objective  resistance. 
The  environment  encroaches  pari  passu  with  the  failure  of  that  faculty 
whereby  the  mind  projects  out  of  itself,  so  to  speak,  an  environment, 
or  revives  in  idea  impressions  received  from  the  environment.  It  is 
the  motOP  element  of  mind  which  is  here  at  fault — the  relational 
element  of  thought,  since  it  is  the  space  attPibuteS  of  bodies  which 
are  involved.     Now,  since  in  the  appreciation  of  these  attributes  of 


122  STATES    OF    DKPRKSSION. 

body  (form,  bulk,  itc.)  tlie  subject  is  active  and  the  object  passive,  it 
results  that  the  motor  constructive  element  of  tlu;  idea  is  the  one  which 
suffers.  In  other  words,  failure  in  the  muscular  element  of  thought 
has  as  its  results  on  the  subjective  side,  enfeebled  ideation  and  the 
sense  of  objective  resistance. 

With  respect  to  the  sense  of  resistance  from  the  environment,  it  is 
of  interest  to  note  its  artificial  production  in  the  reductions  of  con- 
sciousness by  the  agency  of  antesthetics.  To  any  one,  e.g.,  who  has 
been  anaesthetised,  and  who  recalls  his  experiences,  say,  with  nitrous 
oxide,  it  must  be  obvious  how  the  environment  crowds  in  upon  one 
more  and  more,  and  how  the  ego,  or  personality  enslaved  by  its  power, 
finally  feels  that  thought  itself  is  succumbing  to  its  resistless  advance. 

Restricted  Volition. — As  in  the  sphere  of  perception,  so  when 
taking  into  account  consciousness  in  its  totality,  we  likewise  find  the 
same  failure  in  those  complex  muscular  centres,  which,  in  their  adjust- 
ment to  the  environment,  issue  in  what  we  term  conduct.  All 
volitional  acts  categorised  under  this  head  are  the  resultants  of  many 
factors,  or  rather  the  result  of  the  struggle  between  many  contending 
forces.  A  certain  line  of  conduct  or  a  certain  action  being  determined 
upon,  presupposes  the  repi'esentation  in  consciousness  of  the  several 
possible  lines  of  action.  This,  in  other  words,  is  equivalent  to  saying, 
that  various  feeble  motor  excitations  are  represented  in  consciousness, 
and  that  the  stronger  the  aggregate  of  excitations  in  any  special  direc- 
tion, the  more  does  it  tend  to  issue  in  action.  Volitional  actions  are 
hence  preceded  by  nasCent  motOF  excitations.  Such  excitations 
are  the  basis  of  the  act  represented  to  the  mind  in  ideas  which  more 
or  less  vividly  precede  the  act  as  realised. 

In  this  conflict  volition  may  be  enfeebled  as  the  result  of  failure  of 
those  initiative  emotions,  desires,  and  sentiments  which  are  in  abey- 
ance in  states  of  depression;  or  it  may  be  convulsively  restricted  as  the 
result  of  two  opposing  antagonistic  forces,  as  when  such  groups  of 
motor  excitations  divide  the  attention  between  them,  and  the  mind 
sways  from  one  to  the  other  in  hesitation  and  doubt ;  or,  again,  such 
motor  excitation  as  forms  the  impulse  to  action  cannot  be  definitely 
and  strongly  represented,  and  this  enfeeblemcnt  of  muscular  represen- 
tativeness issues  in  apathy  and  inaction. 

A  clearer  conception  of  the  resultant  phenomena  may  be  gleaned  by 
contrasting  the  voluntary  and  the  involuntary  or  automatic  acts.  In  the 
latter,  the  ideal  movements  have  lapsed  in  consciousness — the  stimulus, 
whatever  it  be,  is  followed  so  rapidly  by  the  appropriate  reaction  that 
the  nascent  motor  excitations  do  not  rise  into  consciousness.  The 
start  of  surprise,  the  suddenly  assumed  attitude  of  self-defence,  the 
mechanical  movements  employed  in  conveying  food  to  the  mouth,  and 


ENFEEBLEMENT    OF    MOTOR    REPllESENTATION.  123 

the  masticatory  actions  following  thereupon,  as  well  as  other  complex 
though  automatic  acts,  have  no  initial  motor  antecedent  represented 
in  our  consciousness ;  yet  all  these  movements  are  exquisitely  co- 
ordinated and  rapidly  executed. 

In  the  enfeeblement  of  motor  I'epresentations  preceding  volitional 
acts  during  states  of  depression,  the  actions  themselves,  if  performed, 
are  sluggish,  mechanical,  and  devoid  of  normal  energy ;  and  herein 
lies  the  distinction  between  healthy  automatism  and  these  abnormal 
states.  The  distinction  is  more  important  than  at  first  sight  may 
be  apparent,  for  upon  it  hinges  the  explanation  of  the  automatic 
freedom  of  maniacal  states,  which  implies,  as  we  shall  see  further 
on,  a  grave  and  more  serious  reduction.  The  apathy  and  sluggish 
reaction  of  melancholia  appear  in  part  due  to  this  want  of  vigorous 
motor  representation;  the  true  characteristic  of  a  normal  and  vigorous 
mind  is  the  vivid  realisation  in  consciousness  of  the  action  or  line 
of  conduct  to  be  pursued — the  ideal  recognition  of  all  alternative 
lines  of  conduct  by  the  contrasting  faculty,  together  with  the  repre- 
sentations of  similar  actions  previously  performed,  with  the  result  as 
affecting  the  organism. 

In  normal  states,  each  group  of  the  feelings  which  we  class  as  desires 
and  sentiments  rapidly  tends  to  swell  the  aggregate  of  its  own  motor 
excitations:  so  rapidly  does  this  natural  attraction  of  "like  to  like"  go 
on,  that  the  contrasting  faculty  whereby  the  result  is  obtained  appears 
often  to  act  with  incalculable  rapidity  by  a  process  which  Spencer 
calls  "automatic  segregation."  This  process  is  impaired  in 
states  of  depression,  and  becomes  sluggish,  feeble,  and  hesitating.  Those 
faint  summations  of  ideal  movements  which  are  aroused  as  the  incitants 
to  volitional  acts  may  mutually  antagonise  each  other ;  and  their  very 
want  of  vigour  will  of  itself  neutralise  that  distinctive  quality  wliich 
enables  the  one  group  to  preponderate  and  overcome  the  other  in 
action. 

To  employ  a  figurative  illustration — thus  do  we  witness  in  the  surgiug  tide 
advancing  upon  a  rocky  shore,  two  waves  diverging  at  an  angle  ;  the  one,  receiving 
fresh  impulses  from  minor  wavelets  which  take  the  same  course,  swells  into  a  rising 
crest ;  the  other,  receiving  no  additions,  subsides  exhausted.  Or,  two  such  waves 
of  different  size  advancing  the  one  upon  the  other,  the  higher,  representing  the 
aggregate  swing  of  numerous  undulations,  overcomes  and  carries  with  it  the  surgiug 
elements  of  the  weaker.  Or  again,  to  illustrate  the  feeble  representations  alluded 
to,  let  us  picture  the  Uniform  ripplets  advancing  by  thousands  on  the  surface ;  from 
want  of  co-operation,  each  maintains  its  own  distance  from  the  other,  no  great  con- 
trasting aggregate  of  movement  is  formed,  collecting  to  itself  stray  pulses  of  force, 
and  hence  all  alike  come  to  the  shore  with  similar  insignificant  results. 

Want  of  vigorous  representation,  enfeebled  contrasting  faculty  of 
thought,  antagonistic  tendencies,  or  lastly,  recession  or  restriction  of 


124  STATES    OF    DEPRESSION. 

those  feelings  which  normally  excite  to  voluntary  reactions,  may  one 
or  all  take  part  in  that  restriction  of  the  ego  which  we  speak  of  as  a 
restrained  volition. 

Here  again,  we  have  suggested  to  the  mind  that  resistance  of  the 
environment  which  inevitably  results  where  subject-consciousness  has 
a  diminished  range.  It  may  at  first  sight  appear  contradictory  to 
speak  of  a  Jail  in  object-consciousness  and  a  rise  in  subject-consciou.s- 
ness  as  issuing  in  a  sense  of  resistance  from  the  object-world,  and  a 
state  of  enfeebled  subjectivity  :  this  is,  however,  the  case,  since  the  less 
definitely  the  mind  conceives  of  external  realities,  the  less  vivid  their 
representations — the  wider  the  margin  for  doubt,  suspicion,  and  ideas 
of  encroachment  from  without.  We  fail  to  grasp  the  environment : 
we  do  not  hioiv  it,  in  the  sense  of  measuring  our  strength  against  it — 
and  hence  ive/ear  it. 

So  again,  the  enfeeblement  of  subject-consciousness  pertains  only  to 
that  "  faint  aggregate  of  conscious  states  which  the  vivid  aggregate 
tends  to  draw  after  them  into  being "  {Spencer),  viz.,  the  ideas  con- 
nected with  the  outside  world,  and  the  representation  of  our  reactions 
upon  the  same — hence  the  faculties  of  ideation  and  volition  are  im- 
paired. Far  otherwise  is  it,  however,  with  the  more  sentient  element 
of  the  self-consciousness — that  mass  of  bodily  sensations,  visceral, 
muscular,  articular,  cutaneous,  and  the  feelings  and  emotions  and 
sentiments  which  in  the  aggregate  constitute  the  sentient  or  passive 
eg'O — it  assumes  a  concentrated  and  exaggerated  intensity,  and  this 
is  what  we  refer  to  as  the  rise  of  subject-consciousness  as  distinguished 
from  the  decline  of  object-consciousness :  a  truly  self-analytiC 
state. 

Failure  of  Personal  Identity. — If,  now,  we  attempt  to  trace 

further  the  decadence  of  mind,  in  progressive  forms  of  mental  disease, 
we  arrive  at  a  very  notable  stage,  and  one  of  profound  import,  when 
the  failure  of  object-consciousness  is  so  far  advanced  as  to  lead  to 
alterations  in  the  patient's  notions  of  his  relationship  to  the  outer 
world,  and  to  a  confusion  in  his  own  identity.*  A  considerable  difier- 
ence  is  observable  in  these  cases  of  confused  identity,  but  the  more 
important  distinction  appears  to  exist  between 

(a)  Cases  of  transformed  identity  associated  with  general  feelings  of 
regard  or  good-will  to  the  outer  world,  and  a  universal  sense  of  well- 
being,  or,  at  all  events,  a  complete  indifference  to  the  environment ; 
and 

(6)  Cases  where,  with  the  transformation  of  the  ego,  the  environ- 
ment or  non-ego   is  also   transformed    in   the  patient's  mind   into   a 

*  See  on  this  point  especially  Pdbot,  p.  107-110;  also  Griesinger's  Mental 
Diseases,  p.  51 ;  cf.  Spencer,  Sully. 


TRANSFORMATIONS    OF    IDKNTITY.  125 

formidable,  encroaching,  and  persecuting  foe ;  whilst  all  its  manifesta- 
tions usually  tend  to  call  up  a  sense  of  repugnance  and  hostility.  The 
ego  may  exist  as  a  double  personality,  each  independent  of  the 
other,  or  the  one  swayed  by  the  other,  and  utterly  dissentient  in  their 
nature.  We  need  not  here  deal  with  these  minor  differences,  but 
rather  consider  the  development  of  the  latter  class,  where  the 
identity  is  transformed  and  the  non-ego  is  estimated  in  terms  of  the 
malign.  It  is  well,  perhaps,  at  once  to  state,  that  these  latter  forms 
appear  to  us  to  arise  out  of  the  various  melancholic  types  of  alienation, 
whilst  the  former  are  educts  of  the  more  purely  maniacal  affections. 

How  does  this  mysterious  transformation  arise  1  The  ego  is  consti- 
tuted by  the  vast  aggregate  of  sensations  derived  immediately  from  the 
body,  which  are  a  complexus  of  all  grades  of  sensory  manifestation, 
from  visual  and  other  special  senses  to  tactual  and  general  sense,  as 
well  as  the  far  less  definite  organic  or  visceral  sensations. 

All  those  ingoing  currents  which  arouse,  more  or  less  definitely,  our 
knowledge  of  the  existence  of  a  body,  its  limbs,  _musculatui-e,  and 
viscera,  conjointly  aid  in  the  elaboration  of  the  ego  or  personal  identity. 
But  the  ego  is  far  more  than  this.  We  must  associate  therewith  those 
representations  of  the  same,  and  moreover  the  ''faint  aggregate,"  as 
Spencer  terms  it,  of  states  aroused  by  presentative  cognitions  of  the 
outer  kosmos. 

Our  sentiments,  ideas,  emotions,  as  well  as  our  memory  of  presenta- 
tive states,  all  alike  go  to  form  that  complex  elaboration — personal 
identity,  which  is  severed  sharply  from  the  "vivid  aggregate"  known 
as  the  non-ego — the  physical  in  contradistinction  to  the  physiological 
environment.  Now,  since  in  all  normal  states,  the  internal  order 
bears  a  definite  relationship  to  the  "outer  order"  of  things,  when 
either  of  these  is  profoundly  disturbed,  the  identity  tends  to  suffer 
considerably,  as  indicated  by  Sully.  We  are  all  acquainted  with 
transient  confusion  of  identity,  in  those  waking  states  when  we  fail  to 
realise  the  impressions  suddenly  received  from  the  environment ;  and 
were  the  latter  completely  and  suddenly  transformed,  we  should  fail 
to  restore  immediately  the  balance  necessary  to  re-establish  our  own 
identity. 

So,  when  the  internal  mechanism  is  deranged,  and  the  orderly 
relationship  of  inner  to  outer  kosmos  is  confused,  personal  identity  is 
apt  correspondingly  to  suffer.  We  have  already  seen  how  this  may 
occur  in  the  progressive  failure  of  object-consciousness. 

The  failure  to  appreciate  external  relationships,  again,  is  associated 
with  that  gathering  gloom,  that  sense  of  outward  resistance,  fear,  and 
insecurity  of  the  non-ego  already  alluded  to.  Impressions  from  the 
outer  world  fail  to  arouse  the  normal  representative  states  of  cogni- 


126  STATES    OP    DEPRESSION. 

tion,  but  aid  in  the  welling-up  of  the  emotional  life  of  the  subject,  and 
it  is  from  this  latter  source  that  falsifications  Of  senSG  arise. 

As  subject-consciousness  becomes  nion;  and  more  pronounced  with 
failure  of  object-consciousness,  all  impressions  alike,  received  from  the 
non-o2jo,  become  the  pabulum  for  the  growth  of  an  all-pervading 
effOism.  The  subject  broods  over  his  multiform  and  novel  feelings — 
niorl)id  introspection  and  egoistic  musings  replace  the  healthy 
altruistic  feelings  and  sentiments  :  and,  since  the  emotional  life  is 
itself  in  part  the  origin  of  representative  cognitions  of  the  outer  kosmos, 
so  oiU  of  this  source  there  novj  arise  falsifications  of  the  environment. 

The  pervading  gloom,  the  sense  of  objective  restriction,  and  the 
emotional  states  so  aroused,  attract  to  themselves  like  groupings  of 
ideas—"  attempts  at  explanation,"  as  Griesinger  has  it ;  and  this 
state  progressing,  tends  eventually  to  the  establishment  of  a  neW 
nexus  of  ideas  correlated  to  impressions  received  from  without,  in 
lieu  of  the  old  and  normal  relationships  pre-existing.  It  would  be  a 
fallacy  to  assume  that  the  falsifications  of  the  environment  irrecede  the 
emotional  disturbance,  or  that  delusions  of  persecution  beget  gloomy 
and  malignant  passions — this  would  really  invert  the  actual  sequence 
of  phenomena.  A  gloomy  emotional  background  begets  a  gloomy 
interpretation  of  the  non-ego,  and  all  delusions  of  persecution  are 
be^ot  in  like  manner  out  of  disordered  emotional  states. 

Such  translations,  if  we  may  so  speak,  from  emotional  realms  to  the  realms  of 
thought  are,  even  in  normal  states  of  mental  life,  of  frequent  occurrence:  they 
peculiarly  characterise  the  poetic  faculty,  and  distinguish  the  purely  emotional  and 
imaginative  from  the  intellectual  type  of  mind;  but,  where  such  emotional  incitants 
to  thought  are  in  themselves  the  product  of  morbid  action,  the  intellectual  result 
of  such  operations  is  liable  to  be  delusive  and  false.  The  more  immediaie  concepts, 
as  we  may  term  those  which  are  the  result  of  pure  intellectual  operations,  unas- 
sisted by,  or  only  associated  with,  emotional  states,  are  more  subordinate  to 
accurate  laws  of  logic :  the  more  mediate  concepts,  emotionally  derived,  are  less 
siisceptibl-e  to  such  exactitude  of  classifying  and  grouping.  Such  concepts,  in  the 
morbid  states  now  under  consideration,  are  utterly  illogical,  uuclassifiable,  frag- 
mentary, and  betray  but  the  dixjecia  memhra  of  a  once  rational  mind.  It  appears 
to  us  that  such  distinctions  between  the  immediate  and  the  mediate  knowledge, 
so  acquired  in  the  case  of  the  insane,  are  all-important  in  our  conception  of  the 
genesis  of  these  morbid  conditions  of  the  ego. 

We  have  been  tracing  in  these  mental  operations  the  transformation 
of  the  environment  to  the  alien's  mind  :  out  of  the  old  tissue,  by  a 
species  of  rearrangement  and  reconstruction,  is  woven  a  fabric  repre- 
senting to  him  the  reality  of  external  things,  and  which  to  him  is  the 
only  reality,  but,  to  his  former  state  of  sanity,  is  an  utter  falsification. 
Since  this  morbid  concept  is  projected  out  as  the  actual  kosmos,  and 
since  internal  order  must  correspond  to  the  external,  so  a  transfer- 


TUANSFOllMATIONS    OF    IDENTITY.  127 

mation  of  the  ego  itself  responds  to  this  altered  state — the  former 
identity  is  lost  and  replaced  by  the  new. 

And  here  we  have  an  explication  of  tliat  newly-acquired  freedom, 
which,  at  this  juncture,  appears  to  dawn  upon  the  mind  of  tlie  mono- 
maniac. No  longer  are  phenomena  in  the  outer  world  laboriously 
investigated  and  subordinated  to  rigid  laws  of  logic  and  of  science — 
they  pass,  as  through  a  magic  crucible,  the  morbid  tissue  of  his  brain, 
and  are  transformed  in  accordance  with  no  objective  laws,  but  take 
their  colour  wholly  from  the  morbid  emotional  states  present.  Self- 
creations  arise  with  wondrous  celerity  and  of  protean  form  ;  and  the 
morbid  imagination  conjures  up  fantastic  groupings  utterly  devoid  of 
coherence  and  objective  reality.  A  feeling  of  new  freedom  replaces 
the  old  one  of  restriction  and  aggression  by  the  environment,  and  the 
ego  is  consequently  endowed  with  new  faculties,  new  powers — becomes 
a  mighty  potentate  or  a  god.  Still,  the  environment  is  indelibly 
stamped  with  the  malign  character  which  the  former  emotional  state 
fostered,  and  it  is  only  in  late  stages  of  the  malady  that  such  realisa- 
tion of  a  new-got  freedom  entirely  effaces  the  enmity  of  the  non-ego 
from  the  mind. 

Like  all  sudden  and  extensive  transformations  of  mind,  the  change 
thus  delineated  must  be  accompanied,  as  Griesinger  has  indicated,  by 
great  emotional  disturbance,  "as  the  results  of  the  conflict  between  the 
old  and  the  new."  He  says,  referring  to  the  new  sensations  and 
instincts  which  become  generated  : — 

"At  first  these  stand  opposed  to  the  okl  /  in  the  character  of  a  foreign  thoii,  often 
exciting  amazement  and  fear.  Frequently  their  forcible  entrance  into  the  whole 
sphere  of  the  perception  is  felt  as  if  it  were  the  possession  of  the  old  I  by  an 
obscure  and  irresistible  power,  and  the  fact  of  such  forcible  possession  is  expressed 
by  fantastic  images.  But  this  duplicity,  this  conflict  of  the  old  I  against  the  new 
inadequate  groups  of  ideas,  is  always  accompanied  by  painful  opposing  sensations, 
by  emotional  states,  and  by  violent  emotions. "  * 

It  will  be  seen  that  we  differ  from  the  above  statement,  in  regarding 
the  emotional  perturbation  not  as  the  outcome  of  the  "  conflict  between 
the  old  and  the  new  ego,"  since  it  appears  more  in  accord  with  the 
sequence  of  the  phenomena  to  regard  the  morbid  emotional  storm  of 
this  period  as  being  the  direct  origin  of  the  newly-generated  identity. 

Reductions  such  as  ensue  from  nervous  dissolutions  alone,  can  scarcely 
explain  the  phenomena  with  which  we  meet :  we  must,  in  addition, 
suppose  a  process  of  re-illteg"ration  to  ensue. 

The  level  to  which  the  mental  life  is  reduced  is  still  one  of  active, 
nascent,  mental  life,t  and,  like  all  such  nascent  life,  is  accompanied  by 

*  "Mental  Diseases,"  Sjid.  Sue,  p.  50. 

+  Dr.  Hughlings-Jackson  has  repeatedly  insisted  upon  the  negative  and  positive 
results  of  epileptic  seizures. 


128  STATKS    OP    DEPKKS8I0N. 

much  emotional  disturbance.  Even  in  these  morbid  minds  there  is  no 
reason  to  suppose  that  the  same  process  does  not  proceed,  which  we 
assume  to  occur  in  profound  sleep,  where  the  re-e^iery'isimj  in  planes, 
while  the  individual  is  for  the  time  unconscious,  still  proceeds,  and 
so  mental  potentialities  are  unconsciously  acquired.  So  also  in  the 
monomaniac,  though  the  activities  be  those  of  lower  planes,  still  they 
indicate  developmental  activities,  and  those  groups  of  sensations 
and  ideas  are  conserved  which  are  the  fittest  to  survive  :  irrational 
as  may  be  the  beliefs,  inconsistent  the  new  concepts  with  the  actual 
trutli,  still,  as  Hughlings-Jackson  indicates,  they  are  the  best  possible 
in  the  patient's  state  of  reduction.* 

As  the  tide  of  intellectual  life  retires,  so  does  it  well-up  into  emotional 
states  ;  but  such  emotional  Avave  must  have  its  rebound,  and  this  is 
expressed  in  the  re-integration  Avhich  pervades  the  mental  organism 
with  fresh  ideas  and  concepts;  and  when  such  groups  acquire  a  certain 

definite  cohesion  amongst  themselves,  we  have  the  g^enesis  of  a 
new  identity. 

It  is  only  at  an  advanced  stage  of  dissolution  that  this  transfor- 
mation of  the  ego  can  occur — we  may  safely  assert  that  extensive 
connections  between  distant  nervous  mechanisms  must  be  deranged  or 
dissolved,  ere  that  failure  of  association  of  ideas  could  occur  which 
always  precedes  this  morbid  change.  Fresh  connections  probably 
arise,  through  the  newly-forced  channels  of  the  emotional  wave,  and 
new  centres  of  internal  cohesion  are  begot  and  evolve  the  fresh 
association  of  ideas  of  the  transformed  ego. 

And  here  we  might  note  what  we  shall  later  on  deal  with  more 
fully — -viz.,  those  transformations  of  the  personality  which  characterise 
certain  critical  or  climacteric  periods  of  life — notably  that  of  puberty. 
It  can  readily  be  conceived  how  powerfully  the  mental  life  is  affected 
by  the  re-integration  of  the  new  encroaching  sensations  into  fresh 
instincts,  desires,  impulses ;  or  as  at  the  menopause  by  the  ablation,  so 
to  speak,  of  one  of  the  strongest  instincts  of  the  nervous  constitution, 
the  sexual.  Can  it  be  a  matter  of  wonder  that,  at  these  critical 
periods,  the  risk  to  the   mental    integrity  should   be  great,  or  that, 

*  We  are  prone,  by  the  loose  phraseology  of  common  life,  to  regard  the  subjec- 
tive as  a  permanent  i)0Sfeession — to  speak  of  our  mind  as  a  something  lieyond  the 
simple  active  contents  of  the  moment  and  as  the  accumulated  i)sycliical  activity 
of  our  total  existence  ;  as  if  thoughts  could  be  buttlcd-up  permanently  and 
unchangeably.  It  is  the  material  substratum  of  thouoht — the  organised  nervous 
plexuses — which  represents  the  permanent  and  the  potential  revivabilities  of  former 
experiences,  as  Herbert  Spencer  says: — "Just  as  the  external  nexus  is  that  which 
continues  to  exist  amid  transitory  appearances,  so  the  internal  nexus  is  that  which 
continues  to  exist  amid  transitory  ideas." — Principles  of  Pbijcholofjii,  p.  485. 


THE    PHYSIOLOGICAL    ASPIXT.  129 

in  many  subjects,  permanent  damage  should  ensue  1  So  interwoven 
are  these  instincts  with  the  whole  fabric  of  mind,  that  a  complete 
transformation  of  the  sentiments  and  feelings  follows,  as  the  result 
of  such  incorporation.  Obscure  longings  and  yearnings,  imperfect, 
indefinite  perceptions,  emotional  surgings  wliich  have  no  obvious  origin 
or  purpose,  characterise  a  period  of  perturbation  of  the  mental  life, 
which  may  readily  lead  to  misdirected  efforts  or  morbid  impulse  and 
disease.* 

The  Physiological  Aspect. — In  dealing  with  states  of  mental 
depression,  did  we  attempt  anything  like  an  artificial  division  of  this 
class  of  the  vesania?,  it  would  appear  to  us  more  important  to  lay 
emphasis  upon  the  morbid  pi-ocesses  to  which  they  are  traced,  when- 
ever such  processes  can  with  justice  be  assumed.  It  is  clear  that  the 
symptomatic  indications  of  the  so-called  varieties  of  melancholia  point 
not  so  much  to  a  fundamental  distinction  in  their  essential  nature  as 
to  one  in  their  mode  of  origin  :  they  indicate  quantitative  as  well 
as  qualitative  variations  in  the  nutritive  functions  of  the  nervous 
centres,  and,  hence,  are  roughly  divisible  into  groups,  comprising 
those  which  arise  from  direct  disturbance  of  the  blood-current,  and 
those  which  are  induced  in  the  nervous  tissues  primarily. 

Two  groups  stand  strongly  contrasted  here  :  the  one,  in  which  a 
defective  cerebral  circulation  is  the  more  prominent  feature  ;  the 
other  in  which  an  acute  nutritional  anomaly  of  the  nerve-centres 
expresses  itself  in  still  more  unmistakable  symptoms.  A  further 
group  may  be  constituted  by  the  vai-ious  qualitative  variations  of 
the  blood-plasma — tOXSemia,  kc. — a  group  conveniently  placed 
between  the  two  former.  It  will  at  once  be  evident  that  this  is  a 
very  arbitrary  grouping,  the  one  condition  being  often  associated 
with  the  other  —  nay,  evolved  out  of  the  other.  Thus,  defective 
circulation  leads  eventually  to  grave  nutritional  anomalies,  so  that 
the  symptoms  of  the  first  group  may  pass  into  those  of  the  third, 
although  the  usual  result  is  not  its  passage  into  the  acute  but  into 
chronic  forms  of  nutritional  impairment.  Again,  quantitative  and 
qualitative  variations  of  the  blood,  affecting  centric  nutrition,  may 
co-exist,  whilst  such  nutritional  disturbance  of  the  nerve-centres  reacts 
again  upon  their  blood-supply.  Yet  this  inter-dependence  of  func- 
tionally related  systems,  although  it  renders  any  sharp  demarcation 
into  separate  groups  impossible,  does  not  impair  the  practical  value 
of  a  division  into  the  three  groups,  since  it  always  holds  good  that 
we  may  cleai'ly  distinguish  those  affections  in  which  the  2^'''ominent 
indication  is  that  of  simple  depressed  circulation,  from  a  state  in  which 

*  See  on  this  subject  the  section  on  the  "Insanities  of  the  Period  of  Pubes- 
cence." 


130  STATES    OF    DEPRESSION. 

the  vitiated  quality  of  the  blood  chiefly  appeals  to  us,  and  lastly, 
from  those  grave  affections  in  which  acute  and  chronic  n^itritio^ial 
anomalies  are  the  chief  factors  concerned. 

States  of  defective  circulation  will  comprise  all  the  simpler  forms  of 
melancholia  characterised  by  lowered  cerebral  activity.  Excitations 
from  the  environment  do  not  arouse  the  normal  reaction  ;  they  are 
sluggishly  transmitted,  slowly  elaborated,  and  wholly  fail  to  react 
with  due  vigour  or  purposive  result.  The  registry  of  all  impressions 
is  faint  or  imperfect,  the  latent  period  prolonged,  the  reaction-time 
delayed. 

The  very  earliest  signs  preceding  genuine  pathological  depression 
are  really  the  symptoms  of  cerebral  anjemia  and  nervous  exhaustion. 
The  cerebral  functions  are  torpid,  there  is  diminished  activity  both 
of  the  impressive  and  of  the  expressive  realms  of  the  cortex,  as  above 
described,  and  negative  states  predominate  throughout.  The  subject 
is  heavy,  languid,  sleepy;  frequent  yawning  occurs — not  the  insomnia  of 
a  more  advanced  stage;  intellectual  efforts  are  oppressive,  and  thought 
becomes  dreary,  monotonous,  and  painful.  If  the  warnings  thus  afforded 
be  disregarded,  there  arises  the  frequent  recurrence  of  a  painful  idea, 

occasional  sensory  hallucination,  sleeplessness,  all  indicative  of 

a  commencing  pathological  change — of  impaired  centric  nutrition. 
In  the  earlier  stage,  where  warning  is  not  taken,  and  where,  despite 
such  clear  evidence  of  cerebral  exhaustion,  the  brain  is  still  made  to 
do  its  daily  round  of  duty,  in  a  state  utterly  inadequate  for  such  exer- 
tion, unless  absolute  rest  be  here  enjoined,  the  next  step  will  certainly 
issue  in  patholOg"ical  depression.  The  morbid  nature  of  this 
change  is  sufficiently  evident  in  the  fact,  that  the  diurnal  cycles  of 
nutritional  rhythm  are  frequently  inverted,  or  at  least  gravely  dis- 
turbed. 

Viewed  from  the  mental  aspect,  the  highest  psychical  operations  are 
first  enfeeT)led :  abstract  thought  becomes  oppressive  or  impossible ; 
attention  impaired  or  restricted ;  sensations  are  less  vivid,  and  per- 
ception is  incomplete  or  wanting  in  detail  or  imaginative  vigour — the 
representative  faculty  especially  being  enfeebled.  Apathy  and  indif- 
ference to  the  surroundings,  associated  with  painful  gloom,  pervade 
the  mind,  betraying  the  decline  of  object-consciousness  and  the  rise 
of  subject-consciousness.  *  In  these  states,  the  reaction  on  the  outer 
Avorld  may  be  characterised  by  fitful  irritability,  impatient  conduct, 
sluggish,  mechanical  actions,  or  by  entire  suppression  of  volitional 
initiative.     Both  sensorial  and  motorial  functions  are  sluggish  or  in 

*  So  the  converse  of  an  over-active  circulation  reveals  itself  in  increased  cerebral 
activity — often  in  extraordinarily  vivid  memories.  This  we  see  in  fevers,  also  after 
the  use  of  certain  drugs,  as  opium,  hashish,  &c. — (Ribot,  Op.  c'tt.,  p.  198). 


THE    FULMINATING    PSYCHOSES.  131 

abeyance,  and  the  functions  of  organic  life  arc  all  depressed.  The 
vitality  of  the  organism  as  a  whole,  being  largely  dependent  upon  the 
activity  of  the  nervous  centres,  must  necessarily  suffer  when  this, 
inipoi'taut  regulative  system  is  deranged  :  the  condition  is  truly  one 

of  devitalisation— life  is  carried  on  at  a  lower  level. 

Should  the  nutrition  of  the  nerve-centres  suffer  materially,  a  fresh 
series  of  symptoms  is  aroused :  illusory  states  and  hallucinations 
disti'act  the  attention — the  mental  pain  and  disquiet  is  intensified 
thereby  :  apathy  and  indifference  may  be  replaced  by  timidity,  fright,. 
or  terror ;  and  the  reaction  becomes  expressive  of  such  emotional', 
states — restless  movement  and  agitated  demeanour  replacing  the  former 
negative  condition.  All  this  indicates  impaired  nutrition  of  the  nerve- 
centres,  owing  to  the  defective  supply  of  blood  :  the  nerve-cells,  im- 
poverished, exchange  their  normal  functional  irritability  for  an  exag- 
gerated abnormal  explosiveneSS,  and  fitful  irregular  discharges 
replace  the  rhythmic  outflow  of  the  nervous  discharges  which  regulate-- 
the  subordinate  centres  and  relational  apparatus  of  animal  life. 

These  nutritional  anomalies  reach  their  climax  in  the  third  group  tO' 
which  I  have  referred,  the  explosive  or  fulminating  psychoSeS, 
These  affections  are  characterised  by  the  suddenness  and  explosive 
nature  of  the  nervous  discharge,  which  relieves  the  pent-up  and  accumu- 
lating energy  of  highly  unstable  centres.  In  lieu  of  the  equable 
rhythm  of  discharge  and  repair,  corresponding  to  the  wants  of  the 
organism,  and  adapting  it  to  its  environment,  there  is  disproportionate 
accumulation  of  energy ;  the  centres  are  brought  up  to  a  degree  of  high; 
nutritional  instability,  and  the  least  excitant,  however  trivial,  may,, 
like  the  spark  to  the  fulminate,  issue  in  an  explosion  of  serious  inten- 
sity.    The  nerve  pulse  is  irregular,  fitful,  intermittent. 

This  group  comprises  certain  varieties  of  so-called  impulsivfr 
insanity — the  homicidal  and  suicidal — the  subjects  of  epileptie 
neuroses,  and  affections  arising  at  the  climacteric   cycles. 

The  cortical  expanse  of  the  cerebral  hemispheres  is  certainly 
the  site  of  the  highly  representative  and  re-representative  opera- 
tions :  a  defective  circulation  here  results  in  a  genuine  starvation 
of  the  nerve-elements.  How  does  this  starvation  betray  itself? 
In  replying  to  this  enquiry  let  us  briefly  refer  to  the  case  of  the 
physiological  appetites  for  food,  etc.,  and  parallelise  them  with  the 
case  in  point :  we  shall  then  find  that  all  animal  appetites  are  de- 
pendent upon  two  essential  factors  :  — 

(a.)  The  reception  of  peripheral  excitations  by  a  centric  register. 

{h.)  The  supply  of  blood  to  this  centre. 

Thus,  the  sense  of  hunger  is  the  indication  of  a  want  of  this  due 
excitation  of  the  peripheral  nerves  of  the  gastric  mucous  mend  raiie  ; 


1^  HTATMS    OF    DEPRESSION'. 

and  for  its  alleviation  the  centres  must  receive  impressions  thus 
created.  13ut  excitation  of  the  peripheral  ends  of  the  vagus,  produced 
by  any  mechanical  contact  other  tlian  by  the  ingestion  of  aliment, 
suflices  to  restore  the  nutritive  equilibrium  of  the  nerve-centres  tem- 
porarily. The  rhythmic  pulse  of  excitations  thus  transmitted  to  the 
centruui  calls  up  the  increased  vascular  flux  associated  with  all  brain 
functionising — and  thus,  these  two  agencies  combine  to  raise  the 
nerve-elements  into  their  normal  physiological  condition  of  satiety. 
The  reinstatement  of  molecular  equilibrium  in  the  centric  nerve-cells 
<lepends  not  alone  upon  the  transmission  of  the  physiological  stimuli, 
but  also  upon  the  collateral  flow  of  hlood  to  the  yarl.  So  as  regards 
the  special  senses — the  aljolition  of  the  usual  afferent  impressions 
begets  a  condition  which  is  truly  a  pathological  hunger.  Strikingly  is 
this  the  case  with  the  sense  of  heariwj :  depression  of  spirits  is  a  well- 
niarked  phenomenon  in  suddenly-induced  deafness,  partial  or  com- 
plete. The  depression  so  induced  we  regard  as  a  genuine  instance  of 
.sensorial  hunger — as  the  expression  of  starvation  of  the  nerve-cells, 
thus  deprived  of  the  normal  ingoing  currents. 

Sameness  and  monotony  of  sensory  impressions  produce  identical 
states ;  and  the  want  of  "  a  change "  is  nothing  more  than  the  ex- 
pression of  this  physiological  hunger  of  the  nerve-centres. 

On  the  other  hand,  the  more  highly  representative  the  special-sense 
ikeulty  is  in  its  evolution — the  less  dejJendent  is  it  in  this  respect  upon 
presentative  excitations ;  and  thus  the  sense  of  siylit,  when  similarly 
affected,  fails  to  indicate  in  the  same  notable  degree  a  corresponding 
<iepression  of  the  emotions — idealising  or  centi-ic  initiation  so  com- 
pletely supplementing  the  loss  that  the  results  are  far  different :  yet,  if 
the  sphere  of  such  operations  is  in  itself  implicated,  if  the  nervous 
mechanisms  initiating  representative  processes  are  starved  out  by 
•deficiency  of  blood,  then  there  is  begotten  a  corresjionding  hunger  of  the 
brain-cell.  For,  cerebral  activity  in  these  realms  being  restricted,  as 
shown  in  the  poverty  of  active  ideation  and  thought,  there  is  an  arrest  of 
<iiffusion-currents  provocative  of  the  pleasurable  emotional  states  which 
always  accompany  healthy  energising  of  these  centres.  Corresponding, 
•therefore,  to  the  dreariness  of  thought  in  cognitive  realms,  we  have 
hi.  the  region  of  feeling  such  painful  mental  depression  as  accords 
with  what  we  should  term  the  hunger  of  the  brain  cell. 

Again,  those  ganglionic  structures  which  are  the  regulative  centres 
■for  the  organs  of  vegetative  life,  subserve  the  wants  of  the  system 
■fck rough  the  agency  of  an  inscrutable  law  of  nutritional  rhythm, 
differing  for  each  organ  concerned :  yet,  whether  we  consider  the 
ganglia  connected  with  the  visceral  sensations,  or  those  which  receive 
epirpcriplieral  excitations,  as  those  of  the  special  senses — i.e.,  whether 


GENESIS    OF    PAINFUL    AND    PLEASURABLE    STATES.  UiS 

the  physiological  stimuli  arc  continuously  received,  or  have  intervals 
of  some  duration,  or,  as  in  the  case  of  the  heart,  arc  erjuahle  and 
periodic — in  all  cases  alike,  the  excitation  of  such  centres  depends 
much  in  its  degree  upon  a  due  supply  of  blood  to  the  part ;  unless 
this  be  the  case,  the  centre,  exhausted  by  discharge  and  not  renovated 
by  due  nutritional  flux,  must  lose  in  its  excitability. 

Further,  this  exhaustion  means  a  weakenincj  of  that  associative  ajfinitij 
which  arouses  correlative  centres,  and  which  is  the  physical  basis  oT 
ideal  association.  In  like  manner,  the  directive  agency  of  such  ex- 
hausted centres  must  be  enfeebled,  and  the  blending  of  imjiressions 
and  associated  states  into  the  "serial  line  of  thought"  [Spencer) 
must  be  correspondingly  enfeebled.  As  we  shall  see  further  on, 
this  weaving  of  the  crude  material  into  forms  of  thought  becomes  a 
greater  and  yet  greater  effort:  "  gang'lionic  fpiction,"  as  Pvomanes 
aptly  terms  it,  becomes  arrestive  of  the  higher  processes  of  thought, 
and  this  resistance  in  the  intellectual  sphere  is  associated  with  a 
difiusion  towards  the  more  purely  emotional  sphere. 

Painful  and  Pleasurable  Mental  States.— Since  these  states 

form  so  important  an  element  in  conditions  of  mental  depression  and 
exaltation,  it  will  repay  us  here  to  summarise  briefly  our  views  as  to 
their  nature. 

Mental  pain  has  been  defined  as  the  result  of  iinder-action  or  over- 
action — its  antithesis,  pleasure,  finding  a  place  midway  between  these 
extremes ;  as  though,  we  might  say  figuratively,  an  ocean  of  sluggish 
waters  and  of  stormy  billows  lay  on  each  side  respectively,  with  a  mid- 
region  of  rippling  sun-lit  wavelets.  We  think  this  definition  fails — 
under-action  certainly  leads  to  apathy  and  torpor — over-action  to  all  the 
various  grades  of  painful  mental  states;  yet,  the  essence  of  this  mental 
pain  is  surely  not  over-action,  but  pent-up  activity.  jMental  pain 
varies  in  degree  from  mild  indefinite  gloom  up  to  extremes  of  anguish 
and  despair,  in  which  restricted  volition  is  replaced  by  agitated  and 
frenzied  movement.  Now,  immediately  the  sphere  of  object-conscioiis- 
ness  declines  in  functional  activity,  the  minus  quantity  of  the  one  sphere 
becomes  the  plus  quantity  of  the  other;  which,  in  physiological  terms,, 
implies  that  ingoing  nervous  currents  which  normally  would  arouse 
appropriate  reactions  in  the  intellectual  and  motor  realms,  become 
difiused  in  the  realms  of  feeling  and  emotion  :  what  is  lost  for  per- 
ception is  gained  in  feeling.  The  restricted  accumulation  of  energy 
is  surely  at  the  basis  of  states  of  mental  pain.  If  we  allude  to  suck 
states  as  the  result  of  under-action,  the  under-action  is  distinctly  that 
of  the  higher  planes,  whilst  there  is  a  corresponding  surjolus  of  activitij 
aroused  in  the  subordinate  planes  of  feeling  and  emotion.  The  so- 
called  states  of  over-action,  again,  are  similar  conditions  more  defnitelif 


134  fTATKS    OF    DKPKESSIOX. 

<exp)'e8sed — the  over-action  being  that  of  the  recipient,  afferent,  or  im- 
pressive sphere,  with  a  corresponding  under-actiou  of  the  efferent, 
intellectual,  and  exi)ressive  sphere — in  fact,  all  grades  of  mental  pain 

Arc  dependent  upon  over-action  on  the  impressive  and  restricted 
activity  on  the  expressive  plane. 

In  normal  states,  ingoing  currents,  or  impressions  centrally  initiated, 
Are  translated  into  realms  of  motor  activity  or  high  intellectual  phases; 
in  states  of  mental  pain,  such  translation  is  restricted,  and  such 
activities  expend  their  energy  in  those  diffused  spreading  discharges 
which  are  the  correlatives  of  emotional  conditions. 

We  find  pleasurable  states  invariably  associated  with  the  translation 
oi  feeling  into  ilwuijld  and  action:  we  likewise  find  iiainful  mental 
states  associated  with  the  surging  tide  of  feeling  vainly  struggling  to 
iburst  the  barriers,  in  order  that  it  may  appear  under  the  varied  forms  of 
intellectual  or  muscular  activities :  yet,  we  find  all  degrees  of  the  latter — 
from  that  of  high-strung  emotional  potentiality,  down  to  those  minor 
states  where  feeling  is  expressed  in  terms  of  general  gloom  or  irritable 
impatience  and  fi'etfulness — passing,  in  fact,  towards  states  where  feel- 
ing as  a  higher  emotional  state  seems  well-nigh  abolished,  and  passive 
indifference  and  apathy  indicate  a  purely  negative  state  of  mind.  These 
latter  cannot  be  comprised  under  the  head  of  states  of  mental  jiain, 
however  consistently  they  may  be  classed  as  states  of  mental  depression 
or  anorexia. 

The    Reaction-Time    in    Melancholia. — Any  estimate  of  the 

reaction-time  in  health  or  disease  must  take  account  of  many 
possible  sources  of  error  ;  and  such  fallacies  are  but  intensified  when 
dealing  with  the  insane  mind.  A  large  proportion  of  the  insane  do 
not,  of  course,  admit  of  such  methods  of  examination :  and  even 
amongst  such  as  cheerfully  respond  to  experimentation,  a  certain 
proportion  are  likely  to  falsify  results  from  individual  peculiarities, 
and  the  unpredicable  vagai'ies  of  the  insane  :  delusional  cases  are  in 
this  connection  the  most  doubtful  subjects.  Where  the  reductions 
involve  much  impairment  of  memory,  or  profound  mental  torpor,  the 
test  of  reaction-time,  however  taken,  is  perfectly  futile  and  unreliable : 
and  it  is  only  in  those  instances  of  incipient  mental  derangement,  where 
the  intellectual  operations  are  not  grossly  involved,  that  a  failure 
in  the  energy  of  cerebral  reflex  can  l)e  regarded  as  of  important  signifi- 
cance. 

In  applying  the  test,  the  patient  should,  so  far  as  possible,  be  made 
to  take  an  interest  in  the  experiment,  and  this  can  frequently  be  done 
•with  great  success,  by  a  little  tact,  even  in  serious  cases  of  melancholic 
depression,  or  acute  maniacal  outbursts.  Each  subject  should  be 
repeatedly  tested  short  of  actual  fatigue  ;  and  no  average  sti'uck  of  the 


REACTION-TIME    IN    HEALTH    AND    DISEASE. 


135 


rapidity  of  reaction  from  less  than  twenty  trials.  In  our  own  experi- 
ments with  the  insane  we  have  restricted  ourselves  to  the  estima- 
tion of  the  total  time  required  for  reaction  to  the  stimulus  of  sound 
or  light;  and  have  not  attempted  to  investigate  the  more  complex 
reaction-time  of  a  more  involved  process.  "We  have  employed  one  of 
the  instruments  devised  by  Mr.  Galton  for  anthropometric  experi- 
ments, and  found  it  admirably  suited  for  the  purpose. 

The  general  results,  so  far  obtained,  would  indicate  a  decided  2^Tolon- 
fjation  of  the  reaction-time  in  many  forms  of  insanity.  Simple  affective 
forms — as  in  melancholic  depression  or  maniacal  excitement  of  a 
simple  nature — as  well  as  insanity,  the  outcome  of  alcoholism,  or  of 
■epilepsy,  and  associated  with  general  paralysis — were  made  the  subjects 
•of  enquiry.  In  none  of  these  were  the  results  more  strikingly  uniform 
than  in  alcoliolic  forms  of  insanity,  where,  after  eliminating  every 
probable  source  of  fallacy,  the  reaction  to  an  optic  stimulus  was  almost 
invariably  delayed,  and,  in  most  instances,  the  reaction  to  the  acoustic 
stimulus  was  likewise  involved.  None  of  the  patients  tested  suflei-ed 
from  any  serious  degree  of  dementia,  such  as  would  have  prevented 
their  fully  entering  into  the  interest  of  the  trial. 

In  general  2^c(,ralysis  also,  the  same  delay  in  reaction  occurred,  but 
for  such  cases  we  must  refer  the  reader  to  the  series  of  experiments  as 
given  in  the  section  treating  of  these  forms  of  derangement.  Here 
"we  more  particularly  desire  to  record  the  results  obtained  from  the 
subjects  labouring  under  melancholic  depression,  simple  or  otherwise. 
In  the  following  table  we  have  contrasted  the  results  obtained  from  a 
series  of  individuals  presumed  to  be  healthy,  and  from  the  subjects  of 
more  or  less  acute  melancholic  depression  : — 

Reaction-Time  in  Health  and  Disease. 


Self, 

E.  H. 

T.  H. 

R.  L. 

D.  A., 

R.  \V.,  Simple  MelancJiuli'i, 

M.  L.,        „ 

S.  W, 

J.  W. 

G.  A. 

C.  K. 


Acoustic  Stimulus. 
Sec. 

•13 


,  Climacteric  Mdanclmliu, 
,  Hjjpochomlriacal   ,, 
,  Ddwiional  ,, 


•15 
•IG 
•13 
•16 
•29 
•22 
•29 
•23 
•20 
•14 


Optic  Stimulus. 
Sec. 

•16 
■17 
•18 
•21 
•21 
•30 
•25 
•29 
•24 
•26 
•24 


With  the   above  we  also  contrast  the  results  given  in  a  table  by 


Acoustic  Stimulus. 

Optical  Stimulus 

Sec. 

Sec. 

.     O-HO 

0  200 

.     Ol.-)! 

0-225 

.    o-i,so 

0-1 88 

.     0-1 S-2 

0-194 

.     Uii28 

0-175 

.     ()18(;0 

0  150G 

.     ()-l'2-i 

0-191 

.     0  120 

0-193 

13G  STATES    OF    DEPRESSION. 

von  Kries  and  Aiurbacli,  oinbraeing  the  investigations  of  several 
observers  *  :— 

Observer. 

Hirscli, 
Hankcl, 
Doiulurs, 
Von  Wittiuli, 
Wumlt, 
Exner,  . 
Auerljach, 
Von  Krics,     . 

It  will  be  apparent  from  tlie  observations  on  healthy  subjects,  that 
•whereas  from  -^jf^  to  y^j^^  of  a  second  formed  the  limit  of  variability 
for  acoustic  stinmU,  and  -j^j^'^^  to  -j-y-^  for  visual  stimuli — in  the  insane, 
the  former  is  only  exceptionally  below  -f^^,  and  the  latter  rises  from 
_2^^  to  y"~  of  a  second.  In  healthy  states  the  reaction  to  visual 
stimuli  is  slower  than  to  acoustic  impressions  : — 

There  seems  good  reason  to  suppose  that  the  reaction-time  of  siii^lit  is  necessarily 
longer  than  that  of  hearing  or  touch,  on  account  of  the  photo-chemical  nature  of 
its  more  immediate  stimulus.  One  observer  (von  Wittich)  has  even  gone  so  far  as 
to  conjecture  that  the  s[)eed  of  conduction  in  the  optic  nerve  is  less  than  that  of 
the  other  nerves  of  sense;  it  is  rather  to  be  concluded,  however,  that  the  latent 
time  of  the  sensory  end-apparatus,  and  of  the  cerebral  processes  by  wliich  sensory 
impulses  pass  over  into  motor  impulses  is  different  {Ladd).^ 

The  prolongation  of  the  reaction-time  in  cases  of  insanity  generallijj 
Avould  indicate  a  special  impairment  in  the  visual  as  contrasted  with 
the  auditory  sphere :  both  are  often  involved  ;  but,  the  former  often 
suffers  to  the  exclusion  of  the  latter,  it  being  frequently  observed 
that  a  subject  who  responds  readily  and  normally  to  an  acoustic 
stimulus,  exhibits  notable  delay  in  the  response  to  a  visual  stimulus. 

There  are  many  reasons  for  agreement  with  Professor  Ladd  that 
the  distinction  in  reaction-time  for  these  two  kinds  of  stimuli  is  due, 

not  to  a  different  rate  of  conduction,  but  to  the  different  latent 
period  of  end-  and  centric-org'ans :  and  we  may  assume,  with 

nearly  as  mueli  cortainty,  that  in  the  deranged  states  met  with  in  the 
insane,  the  protraction  of  reaction-time  found  is  due,  either  to  im- 
plication of  the  sensory  end-organ,  or  to  the  intra-central  link  whereby 
the  sensory  is  transformed  into  the  motor  impulse ;  the  former  is 
probably  illustrated  by  certain  subjects  of  chronic  alcoholism — the 
latter  in  ordinary  forms  of  affective  insanity. 

*  Arcldv.f.  A'nat.  u.  PhyMol.,  Phys'iolocj.  Ahlh.,  1877. 
t  Elements  of  Phyalolofjlcal  Psychology,  p.  477. 


DKORERS    OF    PATHOLOGICAL    REDUCTIONS.  137' 

Deg"rees  of  Mental  Depression.— Of  the  innumcraLlo  conihina- 

tions  of  mental  syinptoms  cinliraccd  under  states  of  mental  depression, 
certain  forms  present  themselves,  having  many  features  in  common  of 
suffieipnt  distinctive  value  to  constitute  them  arbitrary  varieties  for 
the  purposes  of  systematic  study  :  such  so-called  varieties,  however, 
it  must  be  understood,  are  by  no  means  other  than  purely  artificial  or- 
arbitrary  divisions,  which  are  nevertheless  essential  for  the  orderly 
grouping  before  the  mind's  eye  of  what  otherwise  would  form  but  a- 
chaotic  and  confusing  assemblage  of  facts. 

It  is  thus  we  hear  of  a  purely  affective  melancholia,*  in  Avhich  the 
emotional  or  affective  sphere  is  chiefly  at  fault ;  and  of  a  delusional 
melancholia,  in  which  the  intellectual  or  ideational  sphere  sufters. 

Whilst  fully  recognising  the  utility  of  such  grouping — whereby  we 
keep  in  view  the  more  notable  affective  implication  in  the  one  case, 
and  the  more  prominent  intellectual  perversion  in  the  other — we- 
must  insist  that  the  student  is  here  likely  to  fall  into  the  serious- 
error  of  regarding  such  arbitrary  divisions  as  the  negation  of  a  principle 
which  we  regard  as  one  of  the  greatest  importance  in  our  studies  of 
insanity— viz.,  the  universality  Of  Implication  which  characterises 
mental  disease. 

By  this  universality  of  implication  we  do  not  mean  that  all  mental  facul- 
ties suffer  alike  in  extent  or  degree— this  would  be  obviously  absurd :  but, 
that  however  prominent  and  obtrusive  may  be  the  implication*  of  any- 
special  faculty— however  limited  at  first  sight  may  appear  the  derange- 
ment, further  investigation  shows  that  the  mind  in  its  totality  has- 
suffered.  The  psychological  aspect  of  mental  depression  presented  to 
the  student  in  the  foregoing  remarks,  will  have  prepared  him  for  the- 
recognition  of  this  fact  of  the  universal  implication  of  the  mental  sphere- 
in  cases  of  morbid  depression — as  subject-consciousness  rises  in  intensity,, 
so  he  has  learnt  to  appreciate  the  wane  of  object-consciousness.  It 
matters  not  how  mild  the  form  of  pathological  depression— how  slight 
the  degree  of  mental  pain — object-consciousness  invariably  presents 
this  corresponding  enfeebleraent :  but  this  latter  feature  has  to  be 
carefully  looked  for,  whilst  the  former  is  the  obtrusive  and  prominent 
indication  of  the  derangement. 

We  do  not  here  allude  to  delusional  perversions,  but  simply  to  those 
minor  grades  of  failing  representativeness  Avhich  we  have  already  traced 
in  the  sluggishness  and  poverty  of  ideation,  its  lessened  vigour,  and 
the  dubiety  of  mind  respecting  objective  existences,  which,  later  on, 
culminates  in  delusions  of  suspicion.  When  we  consider  how,  in  tran- 
sient functional  disturbances  falling  far  short  of  pathological  depres- 
sion, we  find  a  gloomy  emotional  tone  associated  so  frequently  with 
a  morbid  suspicion,  bordering  at  times   upon  actual  delusive  states 


138  STATES    OF    DEPRESSION. 

— inconsistent,  irrational  mis  judgments  of  our  fellow-men  and  universal 
<iistrust,  we  may  be  fully  prepared  in  states  of  genuine  melancholia, 
however  mild  in  type,  to  recognise  in  the  sphere  of  the  intellectual 
operations  a  corresponding  wane. 

Whilst  mhior  deyrees  of  pathological  reduction  result  in  a  welling-up 
of  feeling  as  the  more  obtrusive  feature  (simple  melancholia) — dcfpor 
reduciioiis,  resulting  in  more  serious  implication  of  representative 
operations,  issue  in  delusive  perversions  (delusional  melancholia)  as 
the  more  striking  feature,  whilst  the  emotional  gloom,  in  its  place,  aids 
in  the  creation  of  further  delusional  notions  as  "attempts  at  ex- 
planation," to  use  Gi'iesinger's  phraseology. 

It  will  at  once  be  ap[)arent  how  this  view  differs  from  that  which  enunciates,  as 
its  leading  doctrine,  an  afftdlre  origin  for  insanity :  our  own  view  being  that  the 
■relational  and  the  sentient  elements  of  mind  must  be  conjointly  implicated,  and  that 
the  priorltij  of  implication  pertains  to  the  relational. 

Of  the  clinical  groups  arbitrarily  constituted,  from  amongst  the  sub- 
jects of  mental  depression,  we  may  cite  as  the  more  important — 

(a.)  Simple  melancholia. 

(6.)  Melancholia  with  delusiojis,  including  the  hypochondriacal  form. 

(c.)  Melancholia  agitans. 

{d.)  Melancholia  atonita,  or  melancholy  with  stupoi'. 

To  these  separate  groups  we  must  now  devote  some  attention  :  in 
the  first  place,  it  is  necessary  to  indicate,  that  the  varied  states  which 
these  terms  connote  are  the  outcome  of  the  same  morbid  process  in  the 
■cerebral  cortex,  and  represent  but  differoU  depths  of  dissolution — serial 
stages  in  the  same  disease. 

A  still  lower  stage  of  reduction  is  that  of  maniacal  excitement :  and 
"»ve  mention  this  fact  here,  since  it  is  so  frequently  implied  that  mania 
and  melancholia  are  distinct  diseases,  rather  than  ditferent  stages  of  the 
same  moi'bid  process. 

(«.)  Simple  Melancholia. — Under  the  term  of  simple  melancholia 
.are  embraced  forms  of  a  purely  emotional  or  affective  insanity,  where 
there  is  mental  pain  or  emotional  distress  apart  from  obvious  intellectual 
disturbance — if  such  mental  pain  be  abnormal  in  its  intensity  and 
■disproportionate  to  any  exciting  cause,  we  have  a  species  of  simple 
melancholia. 

Here,  at  the  outset,  we  must  (pialify  the  phrase,  "  a  purely  emotional  or  affective 
insanity :"  for  it  requires  but  little  iusight  into  the  operations  of  the  sound  mind, 
to  lead  us  to  the  conclusion  that  so  interblended  are  all  the  mental  faculties  in 
their  mutual  co-operation,  that  no  such  division  can  be  drawn,  in  a  strictly  scientitio 
aense,  between  the  purely  emotional  and  the  intellectual  states.  When  we  speak  of 
.f  motional  states,  we  must  ever  bear  in  mind  that  the  term  connotes  more  or  less 


MINOR    DEGUEKS    OF    REDUCTION.  130 

of  the  intellectual  element  of  mind— that  every  mental  operation  presupposes  in 
its  very  simplest  form— feeling,  memory,  reason,  volition;  or  rather  that  these  are 
but  different  aspects  of  the  same  state.  It  is,  therefore,  only  in  the  greater  pre- 
ponderance of  the  one  or  the  other  factor  that  we  distinguish  between  abnormal 
mental  states. 

Simple  luelancliolia,  tliereforo,  really  embraces  tho.sc  states  of  morljid 
depression  in  which  the  painful  emotional  element  of  mind  preponder- 
ates to  the  exclusion  of  disorder  of  the  more  relational  element ;  or,  to 
be  more  exact,  where  the  disordered  feelings  by  their  inten.sity  and 
obtrusiveness  overshadow  any  slight  intellectual  disorder  which  may 
be  present.  Definite  delusional  states,  therefore,  are  evidently  excluded 
from  our  definition;  reason  still  as.serts  herself;  there  is  no  enfeeble- 
ment  of  memory ;  volitional  control  is  not  withdrawn.  The  cerebral 
dissolutions  which  such  states  of  melancholia  imply  tend  certainly 
tow^ards  a  lower  level,  towards  more  complete  dissolutions — and  the 
psychical  expressions  then  vary  with  it  to  those  of  disordered  reason, 
memory,  and  will :  yet,  for  purposes  of  clinical  study,  it  is  convenient, 
althouo-h  this  tendency  be  obvious  throughout  the  attack  of  insanity, 
to  fix  the  mind's  eye  upon  the  affective  disorder. 

The  subject  may  long  have  struggled  against  the  gradually  increasing 
depression,  and  may  have  concealed  his  actual  state  from  the  notice 
of  relatives  or  associates — any  undue  reticence,  absence  of  natural 
buoyancy,  or  change  in  demeanour  being  usually  explained  away 
upon  any  other  grounds  than  those  of  mental  implication  :  and  thus 
the  barrier  between  simple  functional  disturbance  and  a  genuine 
pathological  process  is  passed  without  notice.  A  universal  gloom 
pervades  his  mind,  and  a  distaste  for  all  previous  avocations  and 
interests  declares  itself :  exercise  and  all  forms  of  recreation  no  longer 
appeal  to  him,  and  a  dull  uniform  level  of  indiflference  is  engendered 
towards  the  outside  world.  Life  has  lost  its  freshness— Nature  pre- 
sents him  with  no  delights,  and  whatever  there  be  of  beauty  or 
happiness  or  gaiety  around,  but  serves  to  emphasise  his  gloom  as  he 
feels  their  want  of  kinship  to  his  nature.  With  still  greater  emphasis 
can  he  say  with  Nature's  poet : 

"  But  yet  I  know,  where'er  I  go, 

That  there  hath  pass'd  a  glory  from  the  earth." 

Retiring  into  the  solitude  of  his  own  self-consciousness,  he  broods 
abstractedly  over  his  alien  state— fully  cognisant  of  the  nature  of  his 
malady  ;  often  dreading  to  reveal  his  condition  to  those  most  interested 
in  his  welfare. 

But  though  the  object-world  has  lost  for  him  its  pleasurable 
aspects,  and  thought  and  feeling  with  regard  thereto  are  laboured, 
restricted,  and  wanting  in  vigour— yet  subjective  states  of  introspec- 


140  STATKS    OF    DKPRKSSIOX. 

tion,  of  self-analytic  activity  are  keenly  dominant,  and  this  self- 
inflicted  torture  grows  apace  as  sleep  is  lost,  as  defective  appetite  and 
sedentary  habits  of  life  still  further  retard  the  processes  of  nutrition, 
and  repair  and  sap  the  foundations  of  his  uu-ntal  vigour. 

It  is  at  this  period  that  suicidal  prompting's  often  come  to  the 
front ;  but,  here  we  see  Reason  asserting  herself — the  patient  recognises 
his  moral  obligations  clearly — often  shrinks  with  horror  from  the 
suggestion — or  may  be  driven  to  implore  protection  such  as  may  be 
afforded  by  asylum  supervision.  Many,  however,  in  the  gentle  forms 
of  depression,  are  equally  conscious  of  a  degree  of  .self-control  which 
enables  them  to  meet  any  such  suggestion  with  perfect  confidence  : 
tlipy  may  utter  the  usual  formula  of  being  wearied  of  life,  but,  with 
the  utmost  self-assurance,  deny  that  they  could  ever  be  induced  to  lay 
violent  hands  upon  themselves.  As  we  shall  see  later  on,  it  is  in 
much  more  serious  nutritional  anomalies,  that  the  helplessness  of  the 
victim  and  the  dread  of  impulsive  acts  prevail,  as  in  the  fulminating 
psychoses.  Every  degree  of  mental  pain  may  prevail  in  the  subjects 
of  simple  melancholia,  from  such  as  do  not  materially  interfere  with 
their  pursuits — home  or  ])usiness  duties,  to  such  as  result  in  utter 
paralysis  of  volitional  energy  :  and,  in  these  cases,  their  daily  wants 
have  to  be  strictly  attended  to — as  they  would  starve  rather  than 
exert  themselves  to  eat. 

If  the  patient  does  not  improve,  a  further  stage  is  reached  in  which 
we  observe  a  still  greater  wane  in  object-consciousness :  the  jaundiced 
view  of  the  environment  is  no  longer  coi'rectly  interpreted  as  due  to 
the  subject's  own  indisposition,  liut  doubts  arise — distrust  prevails — 
and  a  SUSpiciOUS  bGaPing"  towards  those  around  inaugurates  this 
further  state  of  dissolution.  The  patient,  not  actually  deluded,  begins 
to  misinterpret  all  interference,  however  kindly  meant — looks  suspi- 
ciously at  his  nurse — struggles  violently  at  the  most  trivial  attention 
paid  him ;  whilst  the  preparations  for  feeding  him  or  other  necessary 
procedures  may  be  met  with  every  sign  of  terror.  And  yet,  on 
questioning  him,  he  admits  no  definite  deluded  state — is  readily  re- 
assured— only  the  next  moment  to  relapse  into  his  state  of  all- 
prevailing  fear  that  something  may  hapj^en — he  knows  not  what. 
The  volitional  restriction  here  is  serious — self-confidence  is  greatly 
enfeebled,  and  suicide  is  not  unusual :  the  stage  is  one  of  transition  to 
the  more  definitely  deluded  or  acutely  melancholic  forms.  The  follow- 
ing is  a  typical  illustration  of  simple  melancholic  depression: — 

M.  A.  W.,  aged  .sixty-tliree,  a  iiianiod  woman  witli  a  family  of  two  clnUlreii, 
was  admitted  suflt'ering  from  an  attack  of  depression,  whicli  had  commenced  about 
three  weeks  previously.  She  had  an  earthy  complexion — the  cheeks  mottled  with 
dilated  capillaries:  her  bodily  condition  approached  the  obese.     No  pronounced 


DELUSIONAL    MELANCHOLIA.  l-il 

cartlio- vascular  change  was  apparent,  although  the  heart's  action  was  somewhat 
feeble:  the  geuito-urinary  system  appeared  healthy.  It  was  stated  that  she  had 
just  attempted  to  drown  herself  in  a  water-butt.  For  three  weeks  past  she  had 
slept  but  little ;  had  become  more  depressed  from  day  to  day.  From  her  friends' 
statement,  it  appeared  that  she  had  led  a  perfectly  steady,  temperate  life;  had 
never  before  exhibited  any  mental  disturbance  or  eccentricity,  and  was  not  known 
to  have  had  insane  or  neurotic  ancestors.  She  was  exti-emely  depressed,  wept 
constantly,  was  reluctant  to  enter  into  particulars  about  her  mental  state.  She 
admitted  that  she  had  been  failing  in  health  for  some  months  prior  to  her  attack, 
and  that  she  did  not  know  the  cause  of  her  bodily  or  mental  ailment— could  not 
explain  why  she  was  distressed,  but  ^\•as  constantly  the  subject  of  vague  fear,  and 
frequently  asked  what  was  to  become  of  her.  No  delusions  were  apparent:  she 
had  suliered  from  no  hallucinations.  This  condition  continued  for  some  three 
weeks:  she  always  presented  a  most  melancholic  expression,  but  slept  well  at  night 
without  sedatives,  and  only  on  one  occasion  required  forcible  administration  of 
food.  Through  the  day  she  sat  rocking  herself  to  and  fro,  sobbing  aloud,  and  at 
times  became  greatly  agitated.  The  more  acute  symptoms  then  subsided,  and  she 
turned  her  attention  to  household  work.  She  became  more  reticent,  and  when 
pressed  with  questions  grew  miserable  and  wept  bitterly :  could  still  give  no  exidana- 
tion  for  her  fretting.  In  less  than  a  month  she  fully  realised  her  own  improvement 
in  health — grew  more  hopeful,  less  reticent,  but  now  troubled  herself  much  at 
having  attempted  suicide.  She  was  now  given  small  doses  of  opium  and  ether 
(15  and  10  minims  respectively)  twice  dailj',  and  in  a  few  weeks  later  was  cheerful, 
active,  industrious,  longing  to  return  to  her  friends  and  home,  and  left  the  asylum 
some  ten  weeks  after  her  admission. 

(h.)  Delusional  Melancholia. — This  form,  as  before  stated,  we 
regard  as  presenting  us  with  a  deeper  stage  of  reduction  than  that 
of  the  simple  form  of  affective  insanity  (simple  melancholia).  Gloomy 
apprehension  and  suspicion  have  here  passed  into  definite  and  per- 
sistent delusional  states;  and  intense  as  may  be  the  emotional 
implication,  the  intellectual  derangement  now  appeals  more  forcibly 
to  us  :  and,  being  constantly  insisted  upon  by  the  patient,  is  apt  to  be 
regarded  by  the  friends  as  the  real  cmise  of  the  malady.  It  would  be 
quite  apart  from  our  purpose  here,  even  if  it  were  practicable,  to  illustrate 
the  various  features  assumed  by  these  cases  of  delusional  melancholia 
— they  will  receive  sufficient  notice  in  the  sevei'al  clinical  forms  of 
insanity  which  we  shall  deal  with  later  on.  The  perversions  of  the 
intellect  may  apply  to  any  one  of  the  whole  range  of  things  outside  the 
subject,  or  may  be  entirely  restricted  to  the  bodily  and  organic 
sensations  :  or  again,  to  his  relationships  to  another  state  of  existence 
— to  his  moral  being.  An  infinity  of  delusive  notions,  therefore, 
necessarily  presents  itself,  often  in  such  strange  and  contrasting 
combinations  as  to  be  utterly  unclassifiable. 

Px'ominent,  however,  amongst  such  delusive  notions  are  those  which 
deal  with  the  subject's  corporeal  frame — the  head,  the  body,  limbs,  or 
viscera — often  of  a  grim,  and  as  often  of  a  grotesque  character,  and 


142  STATES    OF    DRPUKSSION. 

which,  if  the  attention  lie  riveted  thercuijon,  constitute  tlie  so-called 
hypochondriacal  melancholia.  Then  again,  we  meet  with  de- 
lusions rrlativc  to  tlir  inoml  licing — the  victim  has  committed  tlie 
unpardonable  sin,  or  for  some,  perhaps,  insignificant  action,  his  soul 
is  eternally  lost — or  passages  in  scripture  constantly  recur  to  him 
of  a  gloomy  denunciatory  nature  as  applicable  to  his  own  state, 
forming  one  of  the  class  of  so-called  relig'ious  melancholia.  Or 
again,  the  encroachment  of  the  environment  is  the  more  perceptible 
feature — and  the  mind  conjures  up  those  malign  agencies  therein 
which  are  expressed  in  the  multitudinous  ideas  Of  persecution, 
tyranny,  troachorv.  And  yet  again,  a  well-marked  class  of  patients 
infer  demoniacal  possession,  witchcraft,  or  other  unseen  agency 
as  accounting  for  their  states  of  mental  perturbation.  In  these  con- 
ditions of  delusional  melancholia,  hallucinations  are  not  only  frequent, 
but  often  form  the  chief  material  out  of  which  such  delusional  states 
are  framed.  Aural  hallucinations  more  frequently  occur  than  visual, 
and  both  far  more  generally  than  affections  of  smell  or  taste.  Halluci- 
nations of  smell  are  of  ominous  import — they  are  frequent  associations 
of  irreparable  alcoholic  brain  disease — of  epileptic  states — of  traumatic 
forms  of  brain  disease,  ttc.  In  the  following  case,  however,  we  find 
such  hallucinations  of  smell  in  acute  insanity  induced  by  alcohol, 
but  I'apidly  recovered  from  : — 

M.  A.  S.,  a  iDavried  woman,  aged  forty-eight,  suffering  from  her  first  attack  of 
insanity,  stated  to  have  been  of  ten  days'  duration.  She  liad  lived  an  immoral  life 
for  twelve  years  past,  and  lately  had  been  of  intemperate  habits,  drinking  heavily 
up  to  the  onset  of  her  attack  of  insanity.  She  is  not  known  to  have  inlierited 
insanity.  She  was  of  corpulent  proportions,  her  complexion  duskj%  and  e.xprcssion 
dissipated  :  her  bodily  health  had  not  very  materially  suffered.  On  admission  she 
was  greatly  agitated  and  terrified,  shaking  her  limbs  violently  in  bed,  or  trying  to 
rush  from  the  room.  She  slept  for  a  few  hours  after  taking  .30  miuims  of  paralde- 
hyde. Much  melancholic  agitation  continued  next  day:  she  struggled  violently  to 
open  the  doors,  declaring  "there  was  a  charm  to  open  them,"  that  there  \\as  "a 
woman  after  her  to  bui-n  her,"  that  "  she  wny  the  flames."  The  following  uiglit  six 
hours'  sleep  ensued  upon  the  administration  of  25  grains  of  chloral :  she  awoke 
calm  and  orderlj\ 

At  this  period  she  was  composed,  attentive,  and  coherent,  but  betrayed  the 
presence  of  numerous  delusions  and  recent  aural  hallucinations:  thought  she  wiis  in 
an  asylum;  came  here  for  protection  from  tlie  noise  in  her  own  house.  There  was 
such  shouting  and  calling;  if  ulte  did  not  answer,  then  got  louder  and  louder.  Voices 
kept  calling,  "Mrs.  Birkett,  Mrs.  Smith,  Mrs.  Birkett,  Mrs.  Smith,  come  and  help 
me,  come  and  help  me  out !  "  when  she  asked,  "Who  has  put  j'ou  there?"  thej' 
shouted  "  Rustan,  Rustan,  Rustan  ; "  that  had  been  the  cry  in  her  house  for  the 
last  two  years.  (She  had  gone  to  the  police  for  protection  against  a  man  she  called 
Rustan,  and  had  stated  that  she  then  saw  his  body  blown  up  by  dynamite.)  She 
had  "smelt  an  earthy  smell  like  that  of  a  dead  hodij  in  her  house  for  the  past  few 
weeks."    When  she  went  to  the  police  for  protection,  "hundreds  of  blackguards 


IIYPOCIIOXDRIACAL    MELANCHOLIA.  ^     I^;? 

followed  shouting  after  her."  She  went  the  same  day  to  get  water  from  a  tap  ia 
the  yard.  "She  was  sure  it  was  drugged,  it  dried  up  her  mouth,  which  begaa 
burning  and  swelling;  slie  was  confident  somebody  wanted  to  stab  her,"  As  usual 
in  such  cases,  she  absolutely  repudiated  any  suggestion  of  intemperate  habits. 

Her  calmness  of  demeanour  continued,  but  she  required  a  sedative  each  night 
to  secure  any  sleep.  A  week  later  she  affirmed  that  at  home  she  constantly  heard 
a  voice  from  beneath  a  stone  table  calling  out,  "O  Mrs.  Rustan,  Mrs.  I'ustan, 
0  Mrs.  Birkett,  0  Amy,  come  down  here  ;  I'm  down  here  under  the  stone."  She 
went  and  searched  under  the  stone,  and  saw  what  "would  have  blown  her  up  if  she 
had  remained  in  the  iiouse."  None  of  these  voices  have  been  heard  since  coming, 
to  the  asylum. 

A  fortnight  after  her  admission  she  exhibited  but  very  gentle  depression,  and  for 
the  first  time  began  to  question  the  real  or  imaginary  nature  of  the  voices  heard. 
No  relapse  occurred,  and  in  less  than  two  mouths  from  admission  she  left,  perfectly 
recovered. 

(c.)  Hypochondriacal  Melancholia.— In  this  form  of  delusional 

insanity,  the  morbid  interest  of  the  patient  is  concentrated  upon  his. 
bodily  organism  and  its  functions.  In  healthy  states  of  activity  the 
ingoing  curi-ents  arouse,  as  we  have  seen  (p.  134),  none  but  the 
massive  feeling  of  p/easwra&^e  toell-heing,  and  it  is  only  when  the  bodily 
functions  are  deranged  that  we  become  directly  conscious  of  the- 
existence  of  our  organs.  So  interblended,  so  inextricably  interwoven 
is  the  web  of  sensuous  feeling  produced  by  such  activities,  that  out  of 
it  arises  the  central  core  of  the  personality — the  ego :  around  the  latter 
there  crowd  the  impressions  received  from  objective  existences — the- 
2yhysical  in  contradistinction  to  the  j^^^'l/^'iological  environment ;  yet,, 
these  two  halves  are  dissevered,  and  although  they  help  to  form  the 
aggregate  mind  of  the  individual,  the  characteristic  stamp  of  healthful 
mental  operations  consists  in  the  continuous  and  vivid  realisation  of 
this  distinction  between  the  subject  and  the  object-world. 

In  the  lower  forms  of  life,  we  conceive  of  the  subjective  element  as  forming  by  far 
the  larger  factor  of  mental  states — a  vast  series  of  impressions  received  fropi  the- 
physical  environment  are  not  referred  thereto ;  and,  although  the  appropriate 
reaction  may  occur,  this  by  no  means  proves  that  such  sensations  are  not  referred  to 
some  part  of  the  oi'ganic  or  physiological  environment.  The  higher  we  rise,  the  more 
definite  becomes  the  reference  of  its  own  series  of  excitations  to  the  object- world  ; 
and  this,  iu  certain  special  lines,  we  see  to  a  remarkable  degree  in  certain  insects, 
such  as  bees  and  ants.  In  man,  of  course,  we  attain  the  complete  severance 
between  these  antithetic  halves  which  renders  possible  his  knowledge  of  uatuie  as 
embraced  iu  the  various  sciences. 

We  have  seen  how  the  failure  of  the  one  half  (object-consciousness) 
may  proceed  to  a  serious  extent  without  implicating  the  groundwork 
of  our  being — the  personality ;  and  states  of  advanced  dementia  realise 
this  still  more  fully  :  we  may  equally  well  conceive  how  the  other  half 
(subject-consciousness)    may    suffer    disruption,    if   this    "  SCnSUOUS 


144  STATES    OP    DEPRESSION. 

core"  of  the  pePSOnality  I'l-  implicated  either  by  peripheral  or 
centric  deraiigeiiK-uis.  That  tlie  foniier  is  possible,  we  have  confirmed 
by  numerous  instanc(?s  of  hypochondriasis  with  mental  derangement, 
.arising  from  disease  of  the  abdominal  and  thoracic  viscera  ;  that  the 
latter  occurs,  is  sufficiently  obvious  in  the  excitation  of  similar  states  by 
mental  agencies — the  perusal  of  morbid  and  sensational  books,  obscene 
pamphlets,  and  the  association  with  similar  cases  of  hypo-chondriasis. 

The  anxieties  and  delusions  of  the  hypochondriacal  patient  may 
have  reference  to  any  part  of  his  bodily  organisation:  amongst  the 
insane,  however,  prominence  is  given  to  the  tract  innervated  by  the 
pueuiiioyastric  nerve,  and  thus  the  regions  of  the  throat,  thorax,  and 
.abdomen — the  respiratory,  circulatory,  and  gastro-intestinal  organs — 
.are  peculiarly  the  subjects  of  the  patient's  anxious  attention  and 
•  coinplaint. 

The  hypochondriacal  tendencies  of  the  subjects  of  epileptic  insanity 
.are  almost  invariably  towards  referring  all  their  ailments  to  the 
stomach  and  bowels — obscure  feelings,  pains  or  imaginary  diseases, 
torpidity  or  obstruction,  are  incessantly  dwelt  upon  by  them;  and  in 
most  instances,  if  not  all,  have  some  basis  in  actual  derangement ;  but 
it  is  in  the  constant  brooding  over  these  states,  and  the  exaggerated 
■colouring  of  their  ailments,  that  the  hypochondriacal  condition  is 
revealed. 

In  the  alcoholic  subject,  on  the  other  hand,  liypochrondriacal  notions 
have  reference  often  to  the  peripheral  ends  of  the  nerves  of  common 
sensation :  thus,  they  continuously  examine  their  limbs,  complain  of 
pricklings  and  other  strange  sensations  in  tlie  skin  :  assert  that  they 
are  poisoned,  so  that  the  skin  is  black,  diseased,  or  "corrupted" 
,(see  Alcoholic  Tnsanilij). 

To  take  the  more  frequent  ailments  complained  of  in  hypochon- 
driacal melancholia,  there  is  the  idea  so  frequently  leading  to  obstinate 
refusal  of  food,  that  "  the  throat  is  made  up,"  or  that  the  gullet  is 
wanting,  an  idea  which  persists  in  spite  of  the  frequent  passage  of  the 
feeding-tube.  In  such  cases,  a  spasmodic  stricture  of  the  oesophagus  is 
not  infrequently  met  with  as  an  obstruction  in  feeding — the  spasm  is 
always  high  up  :  it  is  a  reflex  spastic  state  intensitied  at  once  by  the 
introduction  of  the  u'sophageal  tube.  Although  met  with  in  men,  it  is 
■of  more  frequent  occurrence  in  women,  and  then  often  associated  with 
functional  uterine  disturbances,  as  in  the  resophagismus  of  hysterical 
subjects.  Organic  stricture  we  have  very  rarely  met  with  in  such 
subjects;  but  direct  compression  from  enlarged  thyroid  we  have 
frequently  found,  associated  Avith  such  delusive  conceptions  of  the 
absence  or  total  occlusion  of  the  gullet.  Such  patients  are  intensely 
dejected,  often  seen  with  the  head  bent  forward,  the  hands  grasping 


HYPOCHONDRIACAL  MELANCHOLIA.  145 

the  throat,  and  fully  persuaded  that  they  arc  dying  of  inanition, 
whilst  fed  artificially  with  ample  meals.  They  will  point  to  their 
limbs  (often  well  nourished)  as  evidence  of  their  advanced  emaciation  ; 
and  they  will  often  induce  vomiting,  by  irritating  the  fauces  after 
feeding,  declaring  that  the  food  so  introduced  can  do  them  no  good. 

In  like  manner,  other  subjects  declare  that  they  have  no  stomach, 
and  transform  various  dyspeptic  symptoms  into  indications  of  grave  dis 
ease :  they  may  on  these  grounds  resent  any  attempt  at  feeding,  and 
struggle  violently  to  thwart  one's  efforts.  Others  may  take  food 
heartily,  yet  declare  it  does  not  nourish  them,  and  that  they  are 
slowly  undergoing  starvation. 

Obstruction  of  the  bowels  is  a  most  frequent  idea,  aperient  medicine 
is  asked  for  repeatedly,  and  despite  the  daily  action  of  the  bowels,  the 
insane  patient  reiterates  his  belief  that  no  stool  has  been  passed  for 
•days  or  weeks.  Such  patients  are  pictures  of  misery,  importunate 
about  their  treatment,  querulous,  irritable,  wholly  absorbed  in  their 
own  feelings,  and  can  be  induced  to  talk  upon  no  subject  without 
at  once  reverting  to  their  miserable  plight. 

In  other  cases,  the  genital  organs  are  the  source  of  anxiety — the 
subject  believes  himself  to  be  impotent  or  the  subject  of  syjDhilis, 
and  no  possible  argument  can  be  used  to  assure  him  that  his  whole 
system  is  not  permeated  by  the  virus.  One  patient,  at  the  ^yest 
Riding  Asylum,  believed  his  generative  organs  had  been  displaced  : 
another  that  his  sexual  organs  were  diseased  and  mortified.  Numb- 
ness of  the  epigastrium  was  a  sore  grievance  to  another  patient,  who, 
moreover,  believed  that  his  stomach  contained  pins  and  needles.  In 
the  case  of  a  middle-aged  man  who  died  of  tubercular  phthisis,  an 
accident  (from  which  he  had  really  suffered  some  years  since,  and  in 
which  he  fractured  an  arm  and  two  ribs),  was  made  the  basis  of 
•extravagant  delusional  notions.  He  insisted  that  his  skull  was  nearly 
hollow — "half  his  brains  having  been  scattered  about  at  the  time;" 
that  he  also  lost  "two  gallons  of  blood;"  and  that  a  screw  placed  in  his 
bowels  by  some  unknown  agency  caused  him  continual  and  terrible 
agony.  The  strangest  combinations  of  delusional  notions  arise  out  of 
the  most  trivial  disturbances  of  function — slight  constipation,  flatulence, 
heartburn,  eructations,  mild  intestinal  catarrh  are  exaggerated  to 
ludicrous  proportions  :  the  subject  has  a  huge  animal  within  him 
_gnawing  at  his  vitals,  or  is  full  of  serpents ;  or  his  meat  and  drink 
are  poisoned  by  vitriol;  he  is  "full  up  inside;"  or  flames  of  fire  con- 
tinually burn  within  him.  A  male  patient  who  died  at  Wakefield 
Asylum  of  the  marasmus  induced  by  long  continued  refusal  of  food 
and  melancholia,  was  wont  to  believe  himself  covered  with  a  skin 
eruption  from  head  to  foot ;    he  would    also    blow  his    nose   forcibly 

10 


146  STATES    OF    DEPRESSION. 

to  demonstrate  Iiow  liis  liraiu  Avas  gradually  passing  out  Ijy  that 
channel. 

Out  of  these  morbid  sensations  the  hypochondriac  occasionally  con- 
jures up  elaborate  delusions  of  persecution,  as  in  the  cases  of  .f.  V>.. 
<i.  L.,  and  J.  S.  (see  Alcuholic  Insanity).  They  will  lie  in  bed  declaring^ 
their  inability  to  rise  because  they  have  no  body  or  no  legs :  and  one 
well-known  character  at  Wakefield,  when  asked  her  name,  would 
always  reply,  "  I  have  no  name ;  I  am  no-one ;  I  have  no  body,  no 
liead,  no  limbs  ;  I'm  a  voice  ;  I'm  an  echo." 

Burrows  speaks  of  hypochondriasis  as  never  occurring  before  the 
age  of  twenty-five;*  but  Injpochondriacal  melancholia  is  by  no  means 
infrequent  at  puberty :  in  fact,  we  might  well  expect  the  onset  of  such 
a  disturbance  from  what  we  know  of  the  physiological  cycle  of  events 
which  occurs  at  this  age  (see  Insanity  of  Puberty).  "Hypochondriacal 
states  are  sometimes  observed  in  the  years  of  childhood,  and  more 
frequently  at  the  age  of  puberty.  They  are  extraordinarily  frequent 
in  young  people,  and  more  rare  in  advanced  age  "  (Griesinger).  j 

We  notice  in  all  forms  of  hypochondriacal  melancholia,  one  feature 
wholly  distinct  from  that  characterising  most  forms  of  simple  mental 
depression,  and  that  is  the  insatiable  craving  for  sympathy  in  place 
of  reticence  and  ^self-retirement.  This  tendency  renders  hypochon- 
driacal subjects  the  most  unpleasantly  egoistic,  and  the  most  tedious 
of  all  cases  of  insanity :  it  induces  them  frequently  to  stoop  to 
any  depth  of  deception,  and  to  ape  almost  any  condition  so  as  to- 
attract  attention.  It  is  in  such  instances  that  the  hypochondriac 
so  closely  approaches  the  hysterical  type,  that  it  becomes  a  moot  point 
how  to  distinguish  the  one  from  the  other.  One  of  the  most  striking 
instances  of  the  kind  which  I  have  met  with,  was  that  of  a  young- 
tabetic  subject,  in  whom  cerebral  disturbance  supervened,  and  in 
Avhom  this  morbid  craving  for  sympathy  led  to  simulation  of  many 
symptoms,  such  as  voluntarily  induced  eructations,  retching,  and 
exaggeration  of  [his  genuine  tabetic  state,  and  then  to  the  most 
mendacious  and  vindictive,  yet  groundless  attacks  upon  the  attendants 
and  medical  officers.  :J:  In  like  manner,  we  find  patients  who  will 
lie  in  bed,  forcibly  and  continuously  eructating,  or  obtrusively  sham- 
ming efforts  at  vomiting  to  attract  the  attention  of  the  passer-by. 
In  a  case  to  be  referred  to  later  on,  the  patient  utters  loud  exclamations 
of  distress  as  the  medical  officer  approaches ;  or  induces  startings  of  his 
limbs,  which  he  refers  to  electric  shocks  passing  through  his  frame  ;  or 
makes  hideous  grimaces,  if  he  thinks  he  is  observed,  rolling  his  eyeballs 

*  Commenlarks,  p.  4GG.  t  Op.  cit.,  p.  217. 

t  The  case  was  one  of  interest  throughout,  and  has  liccn  fully  detailed  by  my 
colleague,  Dr.  F.  St.  John  Bullcu,  L'mbi,  part  xli.,  April,  ISSS. 


MELANCHOLIA    AOITANS.  147 

about  as  if  in  torture.  In  another  instance  of  hypochondriasis,  a 
female  endeavoured,  for  months  together,  to  attract  notice  by  loud 
belching  noises,  but  found  a  more  ready  means  of  commanding  atten- 
tion by  picking,  scratching,  and  defacing  her  forehead  and  cheeks 
with  her  nails,  presenting  a  most  piteous  aspect :  scarcely  had  she 
recovered  ere  she  recommenced  the  same  practice,  and  only  appeared 
satisfied  by  the  sympathy  it  evoked. 

Occasionally,  the  morbid  epigastric  sensations  induce  unnatural 
cravings,  as  is  the  case  with  hysteric  subjects:  we  have  known  the  case 
of  a  female  hypochondriac  advanced  in  years,  who,  in  this  state,  cleared 
away  gradually  a  square  yard  or  more  of  plaster  from  a  wall  by  con- 
tinuously swallowing  small  fragments,  ere  the  cause  of  the  disap- 
pearance of  the  plaster  was  detected.  This  same  patient  subsequently 
took  to  pulling  out  the  hair  of  her  head  and  swallowing  it ;  by  this 
means,  she  had  become  on  two  occasions  completely  bald  over  the 
scalp :  ere  she  died,  she  manifested  the  still  more  revolting  habit 
of  devouring  excrement.  Yet,  this  woman  even  declared  she- 
had  no  body,  and  would  moan  piteously  for  hours  at  her  forlorn 
condition. 

Aiiother  aged  hypochondriac  would  restlessly  pace  the  rooms  and 
corridors  of  the  asylum  day  by  day,  bleating  like  a  goat  in  distressful 
tones,  a  picture  of  abject  misery.  He  had  been  fed  for  months  together 
twice  daily,  but  his  evening  meal,  purposely  concealed  on  a  scullery 
shelf  by  the  attendant  who  had  discovered  his  weakness,  he  would 
always  secure  and  drink  sui-reptitiously ;  but  he  could  never  be 
induced  to  take  his  other  meals  by  a  similar  stratagem.  In  these 
cases  of  chronic  hypochondriacal  melancholia  in  advanced  age,  dementia 
progressively  advances  and  no  recovery  is  to  be  anticipated. 

Suicidal  tendencies  are  presumed  by  the  friends  to  exist  in  all  cases 
of  hypochondriacal  melancholia,  and  we  frequently  hear  of  attempts  at 
strangling,  hanging,  drowning,  or  other  measures  in  Avhich  we  may 
fairly  conclude  that  a  bona  fide  suicide  was  not  the  patient's  object,  but 
rather  a  morbid  wish  to  attract  attention  to  his  case  :  in  fact,  these 
subjects  very  rarely  make  such  attempts  within  the  walls  of  an  asylum. 
Occasionally,  however,  as  the  outcome  of  alcoholic  intemperance,  we 
meet  with  a  form  of  melancholic  hypochondriasis,  which,  once  recog- 
nised, will  not  again  be  readily  overlooked :  it  is  one  of  hypochondriacal 
delusions  associated  with  extreme  enfeeblement  of  the  will,  and  des- 
perate impulsive  conduct  is  its  invariable  accompaniment  (/.  F.,  J.  S.) 
Such  cases  are  highly  neurotic  by  heritage. 

{d.)  Melancholia  Ag^itans. — We  have  referred  to  delusional  forms 
of  melancholia  as  a  deeper  reduction  than  the  simple  alfective  form  : 
now  such  cases  of  delusional  insanity  frequently  exhibit  acute  symp- 


148  STATKS    OF    DEPRESSION. 

toms  * — i.e.,  restlessness,  incessant  movcniont,  insufferable  anguish,  and 
every  indication  of  an  agonised  state  of  mind — those  forms  of  acute 
melancholia  are  still  deeper  stages  in  reduction :  thoy  are  in  every 
«ense  an  approach  to  the  maniacal  reductions.  By  melancholia  agitana, 
■we  do  not  indicate  this  acuteness  or  intensity  of  mental  pain,  for  the 
actual  pain  is  often  fixr  more  superficial  in  character  than  might  at  first 
sight  be  apparent :  but  wc  denote  by  tliis  term  the  prevalence  of  a 
motor  ag'itation,  Avhich,  in  like  manner,  approximates  to  the 
maniacal  states.  Huch  forms  of  melancholia  may  be  of  short,  but 
usually  are  of  prolonged,  duration,  even  lasting  over  several  years ; 
they  may  form  but  a  stage  in  any  mental  disturbance,  or  may  charac- 
terise the  case  throughout,  to  its  termination  in  recovery,  in  dementia, 
■or  in  deatli. 

The  patient  is  quiet  only  when  asleep ;  rocks  her  body  to-and-fro,  or 
paces  up  and  down  the  room  incessantly ;  the  hands  are  in  constant 
movement,  grasping  the  head,  tearing  the  hair,  rubbing  the  chest, 
pricking  the  skin  until  it  bleeds,  biting  the  nails,  tearing  or  disarrang- 
ing the  clothing — or  huddled  in  a  corner,  her  face  buried  in  her  hands, 
she  sways  to-and-fro,  lamenting  her  fate  in  loud  sobbing,  or  ejaculations 
sufficiently  expressive  of  mental  distress.  Almost  invariably  the 
•delusive  ideas  from  which  slie  suffers  are  prominent  from  the  first — 
her  soul  is  eternally  lost;  she  is  cast  out  from  God  and  the  world; 
she  is  disgraced,  or  has  brought  ruin  upon  herself  and  family. 

Hallucinations  do  not  appear  to  prevail  in  this  form — they  may 
liave  occurred  as  a  prelude  to  this  stage  of  reduction,  and  in  their 
recall  may  constitute  material  for  delusive  ideas.  The  hypochondriacal 
forms  whicli  we  have  just  studied  may  exhibit  this  state  of  motor 
agitation  at  different  periods  of  its  course.  Let  us  take  as  our  illusti'a- 
tion  of  this  form  of  mental  depression  the  following  case,  wdiere,  after 
■an  onset  of  acuts  melancholic  reductions  and  grave  moral  perversions, 
the  patient  passed  into  this  chronic  stage  of  melancholia  agitans  : — 

S.  A.  A.,  aged  52.  and  niarried.  Tlie  medical  certiticate  runs  as  follows— 
■"  Will  not  leave  her  bed,  rocks  herself  about,  moaning  and  repeating  that  she  is 
doomed  to  go  to  hell.  Says  she  can  see  the  flames  of  hell  before  her  eyes  :  that  it 
is  of  no  use  ealini,'  or  doing  anything  in  the  house,  as  she  is  bound  to  go  to  the  bad 
place."  Her  daughter  states  that  patient  got  out  of  bed  to  strike  her,  and  said  : 
"I  could  tear  j^ou  all  to  pieces  :  ^11  my  love  is  turned  to  liatred."  Here,  then,  we 
have  a  case  of  acute  melancholia,  utterly  unfitted  for  home  treatment— tortured 
by  hallucinations  of  the  senses,  and  delusions  based  tliereupon  :  also  b}^  impulses 
to  violence— "I  could  tear  you  all  to  pieces;"  and  grave  moral  iicrversion,  as 
indicated  in  her  confession  to  her  daughter— "  All  my  love  is  turned  to  hatred." 
These  impulses,  if  neglccterl,  would  just  as  readily  issue  in  a  suicidal  act.  They 
indicate  extreme  instability  of  nerve-tissue,  and  the  explosion  must  occur  in  some 

*  Acuta  in  the  sense  of  intensity,  not  of  duration. 


CASE    OF    MOTOR    MKLANCIIOLIA.  149 

form  of  suicidal,  homicidal,  or  (generally  destructive  conduct.  The  patient  had  a 
similar  attack  of  three  months'  duration,  some  twenty  years  ago,  occurring  after 
labour.  Slie  has  had  considerable  anxiety  caused  her  by  a  drunken  husband,  who 
has  squandered  all  his  means,  and  lost  much  property.  A  brother  of  the  patkiit 
hanged  himself. 

The  acutcness  of  the  patient's  symptoms  rapidly  subsided  after  admission,  but 
she  still  remains  the  subject  of  continued  melancholic  agitation.  She  is  most 
demonstrative  in  her  conduct  and  obtrusive  in  expressing  her  mental  ailments- 
Her  states  of  mental  pain  no  longer  well-up  into  explosive  outbursts— in  impulses 
towards  self-destruction,  &c.;  but,  on  the  other  hand,  obtain  continuous  relief 
in  motor  agitation  and  querulous  complainings.  There  is  no  pent-up  energy 
here  as  in  the  case  of  //.  T. :  it  seeks  and  obtains  relief  in  incessant  garrulity. 
She  will  talk  for  hours  upon  her  miserable  state,  swaying  her  body  toand-froj, 
wringing  her  hands  as  in  extreme  agony  of  mind,  and  expressed  herself  one- 
day  as  follows  :  —  "  You  may  think  of  me  talking  in  this  way  that  I  am  out  of 
my  mind,  but  I  am  not.  I  feel  that  agitated  tliat  I  don't  know  what  to  do  with 
myself.  I  feel  that  my  soul  is  lost  by  having  these  burning  feelings  in  my  inside. 
I  was  made  happy,  but  did  not  seem  to  keep  it ;  was  frightened,  and  something 
seemed  to  say  I  was  given  up  to  the  hardness  of  my  heart.  When  in  a  dark 
room  and  my  eyes  were  open,  lights  seemed  to  fall  on  the  pillow — they  were  as 
big  as  a  candle  :  they  are  real.  I  can't  get  a  bit  of  love,  not  for  my  children. 
I  feel  there  is  no  hope  for  me.  I  feel  so  vicious  with  the  enemy  that  I  could  do' 
anything  with  myself.  I  could  see  I  was  lost— I  don't  want  to  hurt  myself,  for  I 
shall  go  to  the  bad  place  soon  enough."  And  thus  she  contmues  for  hours, 
lamenting  her  lost  soul,  and  relieving  her  feelings  by  incessant  repetition  of  scrip- 
tural denunciations  as  applicable  to  her  own  state. 

There  is  here  undoubtedly  a  frittering  away  of  nerve-force  from  ill- 
conditioned  cortical  areas;  but  there  is  a  vast  distinction  between  such 
states  and  the  genuine  agony  of  mind  apparent  in  acute  melancholia.  In 
the  former,  one  is  more  struck  by  the  continuous  self-analysis,  incessant 
introspection,  and  the  fascination  which  the  revelation  of  such  states 
to  others  seems  to  possess  for  such  patients :  by  the  voracious  appetite 
exhibited,  and  the  maintenance  of  good  bodily  health,  despite  all  this 
apparent  distress.  This  accounts,  in  fact,  for  the  chronicity  of  the 
case  :  for  nearly  four  years  this  melancholic  agitation  has  been  main- 
tained, and  so  far  from  exhaustion  ensuing,  the  patient  is  well- 
nourished  and  robust.  In  fact,  the  painful  mental  state  is  far  less  real 
than  one  is  inclined  to  imagine — the  symptoms  falsify  the  actual 
state  :  her  utterances  are  but  formula?  from  frequent  repetition. 

We  recall  one  patient,  the  subject  of  chronic  mania,  Avho  woulcT 
meet  one  every  day  with  a  lugubrious  expression,  and  the  remark  : — 
"  I'm  going  to  be  burnt  to-day — I'm  going  to  be  burnt :  they  are 
building  a  huge  fire  in  the  park,  and  they  are  going  to  roast  me  on  it." 
When  questioned,  she  would  enter  into  minute  details  of  a  horrible- 
crime  which  she  imagined  she  had  committed,  in  whicli  she  had 
poisoned  fifteen  children  with  corrosive  sublimate  :  would  describe 
how  she  deceived   the   mothers  :  hoN^  she   "  watched   the   little  brats 


150  STATES    OF    DEPHKSSIOX. 

partake  of  the  poisoned  meal,  and  wriggle  about  in  their  agony." 
Then  she  would  grin  maliciously  or  shake  with  laughter,  ending  with 
her  accustomed  formula — "  I'm  going  to  be  Ijurnt  to-day." 

Such  cases  impress  us  with  the  superficial  nature  of  what  often 
looks  at  first  like  profound  mental  pain  ;  we  must  remember  the 
peculiar  cunning  of  the  insane,  who  are  always  observant  of  the  eifect 
which  they  produce  on  the  mind  of  the  observer,  tlu.'ir  fondness  for 
mimicry,  extravagance,  and  distortion. 

STATES  OF  MENTAL  STUPOR. 

Contents. — Stii])or  and  Dementia  —  Etiolo.cry  of    Stuporose    States  —  Stupor   anil 
Hypnotism— Stuporose  ^Melancholia— Acute  Primary  Dementia. 

By  states  of  stupor  we  understand  a  suspension  more  or  less  com- 
plete of  the  emotional,  intellectual,  and  volitional  operations  —  a 
suspension  in  contra-distinction  to  an  abolition  of  these  faculties  : 
the  latter  condition  we  denominate  "dementia,"  a  term  which  denotes  the 
absence  of  certain  mental  faculties,  through  impairment  or  destruction  of 
the  mechanism  whereby  such  operations  are  rendered  possible.  What- 
ever be  the  change  whereby  these  faculties  are  suspended,  whether  as  the 
result  of  pressure  on  the  nerve-elements,  the  physical  correlatives ;  or 
the  result  of  the  inhibitory  effects  of  powerful  sensorial  stimuli ;  or 
temporary  circulatory  changes  through  vaso-motor  influence ;  or  ex- 
haustive centric  nervous  discharges — the  distinguishing  feature  is  that 
of  an  arrest,  transient  or  more  enduring,  of  the  intellectual  operations, 
Avhich  may  be  suddenly  re-initiated  under  an  altered  state  of  things. 

x\.s  in  cases  of  dementia,  the  abolition  or  impairment  of  these  faculties 
lias  often  notable  accompaniments  extending  over  a  wide  range  of  the 
cerebrospinal  operations,  in  impairment  of  sensation,  blunting  of  the 
emotions,  enfeeblement  of  volitional  activities — so,  in  states  of  stupor, 
a  similar  impairment  of  the  sensori-motor  functions  is  apparent.  These 
are  the  accompaniments,  but  the  intrinsic  nature  of  stupor  depends 
upon  the  arrest  of  ideation  and  suspension  of  the  intellectual  operations. 

The  insane  present  us  with  every  grade  of  these  states  of  stupor, 
from  cases  of  mild  apathy,  to  depths  of  profound  and  persistent  lethargy, 
in  which  the  subject  closely  simulates  the  aspect  of  genuine  dementia. 

Mild  forms  of  stupor  often  find  their  parallel  in  normal  physiological  life,  as  in 
the  confusion  of  ideas  which  our  waking  moments  arc  occasionally  prone  to  exhibit. 
We  knew  a  medical  friend,  accustomed  to  sleep  heavily,  thus  partially  awakened  by 
the  night-bell,  receiving  the  message,  dressing,  and  proceeding  a  considerable  way 
upon  his  mission  ere  his  destination  and  import  of  the  visit  were  clear  to  his  mind. 

In  these  states,  the  perceptive  faculties  may  correctly  apprehend 
external  things,  but  not  their  relationships  to  ourselves,  and  a  state  of 


ETIOLOGY    OF    STUPOHOSE    STATES.  151 

tro.nsient  stupor  ensues.  The  state  of  post-epileptic  stupor  exhibited 
after  a  series  of  severe  fits  is  interesting  in  this  connection,  as  presenting 
a  similar  mental  obnubilation  to  that  seen  in  the  cases  of  insanity  to 
which  we  now  refer.  The  vacant  gaze,  the  dream-like  look  cast 
around,  suthciently  indicate  the  torpor  of  the  perceptive  faculties : 
with  the  gradual  reinstatement  of  the  mental  powers,  semi-unconscious 
movements  commence — fumbling  of  clothing,  feeling  or  rubbing  of  the 
limbs,  pulling  about  of  furniture,  incessant  restlessness,  and  ill-regulated 
nervous  discharges  which  usher  in  awakening  consciousness.  Such 
restless  movements  betoken  the  re-awakening  mind,  the  re-energising 
of  discharged  centres,  and  find  no  parallel  in  states  of  stupor  where  the 
dormant  intellect  is  shewn  by  sluggish  motorial  reaction,  fixation,  and 
immobility. 

We  frequently  observe,  both  in  epilepsy  and  general  paralysis, 
instances  of  suddenly  assumed  stupor,  often  of  long  continuance  and 
not  necessarily  preceded  by  any  obvious  motor  discharge  or  convulsion : 
undoubtedly,  in  these  cases,  there  has  been  discharge  of  unstable  grey 
matter  from  sensorial  realms  of  the  cortex. 

Thus,  a  case  of  tabes  dorsalis  associated  with  mental  symptoms  has 
shown  us  this  feature ;  whilst  a  similar  case  of  insanity  in  a  tabetic 
subject  has,  on  the  other  hand,  presented  the  post-convulsive  stupor. 

States  of  mental  stupor  may  be  variously  induced  thus — 

(a.)  A  mental  shock,  such  as  the  sudden  commotion  caused  by  joyous 
or  painful  news  in  a  high-strung  sensitive  subject,  may  have  the  effect 
of  inducing  such  conditions  of  stupefaction  :  the  acceptance  of  this  fact 
is  sufficiently  attested  to  by  such  conventional  phrases  as  "transfixed 
with  horror  ;"  "  petrified  by  the  scene  ;"   "  dumb  with  terror  ;"  itc,  ttc. 

{h.)  Nervous  discharges  from  tracts  of  unstable  cortex,  as  in 
epilepsy  and  general  paralysis,  lead  to  mental  stupor  through  exhaustion 
of  the  centres  so  discharged  :  much  here  depends  as  to  whether  the 
centres  so  discharged  have  few  or  many  sensorial  or  psychical  correla- 
tives. 

(c.)  Other  influences  leading  to  exhaustive  expenditure  of  force — 
exhaustive  drains  from  the  system— e.r/.,  phthisis — the  vicious  habit 
of  masturbation. 

{d.)  Acute  forms  of  insanity  are  prone  to  be  followed  by  stupor. 

(e.)  Bromism,  in  like  manner,  whilst  aftecting  the  peripheral  nerves, 
reducing  the  excito-motor  functions  of  the  spinal  cord,  and  inducing 
torpor  and  sluggishness  of  secretions,  leads  to  a  loss  of  centric  energy 
resulting  in  stuporose  states :  and  other  toxremite  have  a  like  effect. 

Cases  of  stuporose  insanity  may  be  studied  with  advantage  in  con- 
nection with  those  exceedingly  interesting  conditions  of  hypnotism, 
which  the  researches  of  Mr.  Braid,  Di-.  Carpenter,  and  more  recently 


152  STATES    OF    DEPRESSION. 

Heidenheim,  Charcot,  and  Richer  have  revealed  to  us ;  and  wliich 
now  assume  a  more  intclligibl(!  form  as  the  phenomena  Lecome  investi- 
gated by  strict  scientific  metliods.  It  appears  tliat,  in  tliese  artificially- 
induced  states,  every  conceivable  degree  of  suspension  of  the  higher 
cerebral  functions  may  be  obtained,  and  the  subject  may  pass  from 
those  light  forms  of  induced  reverie  ("biological  states"),  through 
somnambulistic  and  cataleptic  phases,  into  the  more  profound  stage  of 
mental  lethargy. 

The  nerves  of  cutaneous  sensibility,  the  nerves  of  special  sense,  the 
sympathetic  centres  in  the  medulla,  may  each  be  stimulated — the  two 
former  into  a  greatly  exalted  state  of  sensitiveness.  The  intellect 
may  remain  acute,  but  only  on  that  train  of  thought  for  the  time 
dominant :  or  the  senses  may,  one  or  more,  undergo  notal)le  blunting, 
and  the  reverie  and  state  of  expectant  attention  pass  into  dreaminess 
or  profound  sleep.  Again,  the  muscular  sense  may  be  much  exalted — 
automatism  of  an  elaborate  nature  may  prevail,  reflex  movements 
occur  on  suggestion,  or  tonic  spasm  ensue  from  excitation  of  muscles 
and  tendons.* 

Now,  the  states  of  mental  stupor  wliich  jjrevail  in  the  insane,  exhibit 
features  which  at  times  strongly  suggest  allied  conditions  of  the 
cerebrum  to  those  found  in  the  '*  biolog'ised "  and  "hypnotic" 
subject.  In  them,  the  suspension  of  the  mental  faculties  and  implica- 
tion of  sensation  vary  much  in  degree ;  may  be  suddenly  induced 
and  as  suddenly  relieved:  in  them,  also,  dominant  ideas  appear 
to  prevail  and  cataleptiform  states  may  be  assumed,  or  still  more 
profound  torpor  take  the  place  of  a  half-dreamy  state  of  consciousness. 
In  them,  also,  the  blunting  of  general  and  special  sensation  may  be 
observed — analgesia,  loss  of  taste,  of  appreciation  of  temperature, 
of  sight,  hearing,  or  of  smell,  noted  in  hypnotic  subjects  (Zandois),i 
and  in  those  conditions  which  pre-eminently  favour  what  ai'e  known 
to  be  predisposing  causes  of  hypnotic  and  trance-like  states. 

Mild  stimulation  of  a  special  sensory  tract,  to  the  exclusion  of 
others,  notably  of  the  trifacial,  optic,  and  acoustic,  as  by  the  "passes" 
of  the  mesmerist,  or  the  fixation  of  the  eye  on  a  bright  spot  above  and 
near  the  eye  to  induce  effort  by  convergence,  or  by  soothing  mono- 
tonous sounds — will,  in  many  subjects,  induce  the  hypnotised  state. 
So,  states  of  mental  abstraction,  where  a  monotonous  impression  or 

*  The  earliest  S3iiiptoms  of  lij'pnotism  appear  as  the  result  of  stimulation  of  the 
nuclei  of  the  oculo-iuotor  tract  in  the  medulla  :  there  is  spasm  of  acconiniodatiou, 
restricted  accommodative  range,  the  p.r.  approaches  the  p.p.:  then  stimulation  of 
the  sympathetic  occurs  with  exophthalmos,  widening  of  palpebral  fissure,  dilatation 
of  pupil,  quickened  pulse,  and  breathing. 

t  Landois  and  Stirling's  Physiolojij,  vol.  ii.,  p.  2G9. 


STUPOR    AND    HYPNOTISM. 


108; 


Diminished. 
Diminished. 

Fall. 

Closed. 

Eoll  upwards. 

Contracted. 
Ann?mic  (Hugh- 

Circulation    and 
breathing  slow- 
ed :    i^eristalsis 
and     secretion 
lessened. 

2  s 

-<  O 

i-lM 

Profound  sleep. 

Exalted. 
Exalted. 

Fall. 

Not    anwmic 
[Forder). 

True  Catalkptic 
OR  Somnambulistic  var. 

Intellect  and  senses  acutely 
sensitive:  colourblindness 
on  hypnotised  side  (Heiden- 

helm). 
Normal. 

Normal. 

Light  and  remain  long  fixed. 

No  effect. 

Open. 

Fixed  or  roll  down  with  ab- 
sorbed gaze. 
Dilated. 

Not  anajmic. 

Circulation    and    breathing 

quickened. 

Automatic  balancing :  obeys 
suggestion  and  command : 
occasional  hallucinations. 

ii 

o 

Sleep. 

Exalted. 
Slightly  raised. 

Heavy  and  soon 

fall. 
Resolves  sjJasm. 

Closed. 

]ao11    upwards 
{Charcot). 

Not  anaemic. 

2 

u 

H 
•Jl 

Much  impaired. 

Normal. 
Normal. 

Heavy,  resisting,  soon  fall. 

No  effect. 

Partial  closure  with  fre- 
quent clonic  blinking;. 

Roll  upwards  and  twitch 
convulsively. 

Dilated. 

Heart  &  breathing  natural: 
flushings:  vasomotor  par- 
alysis. 

Consciousness. 

Reflexes. 

Neuro  -  muscular 
hyper-excitability. 

Limbs. 

Massage  of  catalep- 
tic limbs. 

Eyelids. 

Eyeballs. 

Pupils. 
Fundus  oculi. 

Organic  functions. 
Other  features. 

3,  '3 

a  >»- 

n  » 

>  •« 

O  a. 


H- 


154  STATKS    OF    DKPKESSIOX. 

liclea  is  the  sole  subject  of  thought,  and  where  other  impressions  are 
n'oluntarily  excluded,  are  conditions  which  pre-eminently  favour  states 
of  induced  hypnotism  and  stupor.  It  will  be  of  interest  to  tabulate 
.here  certain  prevailing  features  in  the  state  of  stupor  and  hypnotism, 
so  as  to  indicate  more  clearly  any  physiological  or  psychological  relation- 
ship existing  amongst  such  groups  of  symptoms. 

It  would  appear  from  the  foregoing  Table,  tliat  mental  stupor  approxi- 
onates  more  closely  to  the  cataleptiform  type  of  hypnotism,  rather  than 
'to  the  truly  cataleptic  type.  The  subject  is  not,  as  in  the  latter  state, 
.accessible  through  the  special  or  general  senses,  and  suggestion 
•through  these  channels  fails  to  elicit  responsive  movements ;  but,  on 
the  other  Laud,  it  does  appear  that  the  mind  is  often  the  subject  of 

•  dominant  ideas  imposed  through  external  agency,  and  that  the  cata- 
leptiform positions  which  the  body  and  limbs  may  be  made  to  assume, 

•  can  be  plausibly  explained  on  the  principle  of  suggestion  through  the 
muscular  sense. 

Yet,  the  patient  in  these  states  of  stupor  is  not  asleep,  nor  does 
■massage  or  kneading  resolve  the  rigid  muscles  which  have  assumed 
the  cataleptic  state.  Herein,  then,  we  see  how  the  subject  approxi- 
mates to,  and  how  far  he  differs  from,  the  hypnotised  individual.  It 
must  be  added,  that  these  clinical  forms  are  by  no  means  grouped 
together  as  suggestive  of  identical  pathological  states — the  patho- 
genesis may  be  wholly  distinct  for  each  class. 

The  fixation  of  the  limbs  in  artificially-imposed  postures,  would 
.seem  to  indicate  a  dominant  notion  of  the  necessity  for  preserving 
.such  a  posture,  illustrating  the  obedience  induced  to  external  agencies 
■whereby  the  will  is  subjugated — the  subject's  attention  being  reached 
principally  through  liis  muscular  sense. 

The  greater  depth  of  reduction  in  these  states  of  stupor  is  attested 
by  the  fact,  that  suggestions  by  command   fail  to  elicit  such  trains 

•  of  ideas  and  resulting  movements  as  the  hypnotised  will  present, 
dlosing  the  fists  and  advancing  the  arms  of  a  hypnotised  individual, 
and  placing  him  in  an  attitude  of  defence,  will  often  bring  about 
fighting  movements  in  reality  {Gaiy enter);  and  muscular  posturing 
will  elicit  the  associated  mental  states  of  which  it  is  normally  the 
•expression.  This,  of  course,  does  not  occur  in  cases  of  genuine  stupor, 
•or  the  more  profound  reductions  of  "acute  dementia." 

We  see,  again,  simple  forms  of  hypnotism  in  which  the  sole  muscular 
anomaly  consists  in  an  inability  to  open  the  eyelids  or  the  mouth  : 
parallel  states  of  mental  stupor  present  themselves  in  which  the  same 
features  prevail. 

H.  S.  L.,  aged  twenty-six,  a  married  woman,  witli  two  children  ;  the  youngest, 
.an  infant,  aged  nine  weeks,  was  weaned  upon  the  outbreak  of  mental  symptoms 


STUPOR    AXD  HYPNOTISM.  155 

six  weeks  ago.  No  history  of  inheiited  insanity,  neuroses,  drink,  or  other 
vice.  The  labour  liad  been  natural  in  all  particulars.  On  admission,  she  had 
a  very  vacuous  expression  :  "  stared  round  the  room  in  a  vacant  manner :  was 
wliolly  inattentive  to  what  was  said,  and  very  rarely  spoke.  When  questioned 
she  usually  remained  silent,  even  though  the  query  was  repeated  many  times, 
and  efforts  were  made  to  rouse  her  attention;  or  she  repeated  the  concluding  words 
of  the  question,  or  the  words  which  she  heard  uttered  by  a  neighbouring  patient." 
She  was  emaciated  and  antemic :  her  pupils  widely  dilated.  The  thoracic  and 
abdominal  viscera  revealed  no  evidence  of  disease  to  phj^sical  exploration  :  but  the 
bowels  were  torpid,  and  the  tongue  was  foul  and  thickly  coated. 

After  the  operation  of  a  saline  aperient,  patient  was  ordered  a  mixture  con- 
taining 10  grs.  of  ammouio-citrate  of  iron,  and  5  minims  of  liquor  strychnia;  in 
each  dose  {bis  die). 

The  condition  was  one  of  painful  stupor  :  the  expression  was  melancholic  and 
timorous,  or  one  of  complete  stupor,  in  which  she  stood  gazing  vacantly  into 
space :  she  was  silent,  but  occasionally  would  give  utterance  to  monosyllabic 
replies.  Her  habits  were  frequently  negligent.  She  required  feeding  by  hand, 
but  was  induced  in  this  way  to  take  abundantlj\  Her  hands  were  cold  and 
somewhat  livid  :  all  her  movements  were  very  sluggish. 

About  a  week  later,  she  became  one  day  suddenly  and  violently  excited — 
exclaimed  aloud — "Cut  my  throat  and  let  me  die."  Asked  why  she  wished  to 
die,  she  replied,  "Because  I  am  so  shocked."  Then  she  relapsed  into  her  former 
abstracted,  silent  state,  requiring  continuous  attention  on  account  of  her  rest- 
lessness at  night,  her  dirty  habits,  and  her  inattention  to  food. 

A  month  after  her  admission  her  bodily  condition  had  considerably  improved  : 
she  slept  better,  but  was  still  depressed  and  in  a  state  of  semi  stupor :  the 
menstrual  functions  were  in  arrest. 

Slow  improvement  took  place  in  her  bodily  health,  but  ameuorrhcea  persisted 
for  some  six  months,  during  which  period  the  same  treatment,  alternated  with 
iron  and  aloes,  was  maintained.  She  remained  sluggish  in  her  movements  and 
somewhat  depressed  in  spirits,  but  would  freel^^  converse  about  her  state  of  health, 
and  was  eventually  discharged  as  relieved  to  the  care  of  her  husband. 

In  sucli  a  case  as  the  foregoing,  we  see  the  distinction  between  simple 
melancholic  depression  and  the  more  acute  depression  often  associated 
with  stnporose  states  :  whereas  the  gentle  depi'ession  of  the  former 
induces  apathy,  disinclination  for  exertion,  bodily  or  mental,  and 
brooding  silence,  the  latter  may  result  in  one  of  two  conditions — either 
in  the  demonstrative  expression  of  these  painful  states  {inelanchoUa 
agltans) ;  or  in  a  spell-bound  stupor  in  which  the  organism  seems,  so 
to  speak,  petrified  by  its  intensely  painful  mental  state — the  melancholy 
with  stupor  or  the  stupidlte  of  French  alienists. 

Such  patients  are  often  completely  dumb — their  whole  aspect  that 
of  intense  stujDidity  :  but,  if  you  closely  examine  their  features,  you 
will  observe  evidence  of  painful  emotion,  or  intense  anxiety,  of  inex- 
pressible grief,  or  perhaps  a  look  of  extreme  bewilderment  or  concen- 
trated astonishment. 

Numerous  patients,  who  have  suffered  from  melancholy  with  stupor, 


156  STATICS    OF    DEPRESSION. 

liave,  upon  recovery,  recorded  i'ull  details  of  (heir  mental  state  :  they 
are  generally  lahouring  under  some  frightful  delusion,  which  utterly 
sways  their  consciousness  and  will :  the  outside-world  may  be  a  blank 
to  them,  and  their  whole  mental  life  is  subject  to  this  all-absorbing 
delusion.  Perhaps  they  imagine  they  have  committed  some  terrible 
murderous  deed,  or  that  the  end  of  all  things  is  at  hand  :  whatever  it 
be,  the  attitude,  facial  expression,  and  demeanour  indicate  complete 
subjection  to  the  engrossing  delusion.  This  concentration  of  the  mind 
upon  one  painful  idea,  which  sways  like  an  autocrat  the  whole  organism, 
has  been  figuratively  alluded  to  as  a  "crystallised  delusion" — body  and 
mind  are  crystallised  around  one  morbid  idea.  Such  patients  often 
resist  powerfully  any  attempts  at  feeding  or  other  interference,  and  the 
refusal  of  food  is  sometimes  most  persistent. 

Then  come  sudden,  fitful  gleams  of  mind  at  times;  a  rai)id,  hurried 
utterance,  with  as  sudden  a  relapse  into  silence  and  self-absorption:  or 
a  sudden,  mad  attempt  at  self-destruction — an  impulse,  the  direct 
result  of  the  painful  mental  state.  One  should  ever  Ijear  in  mind  this 
suicidal  tendency  in  stuporose  melancholia :  it  is  a  constant  danger  to 
be  feared,  and  all  the  more  since  the  apparent  stujDor  is  more  that  of 
hodUy  activity,  and  one  is  apt  to  forget  that  the  mental  state  is  often 
one  of  intensely  acute  and  painful  strain,  most  liable  to  explosi\'e  acts 
and  impulses  towards  self-inflicted  violence  :  all  such  suicidal  attempts 
in  this  disease  are  frantic  and  determined  in  the  extreme. 

The  following  is  an  instance  of  permanent  mental  enfeeblement 
resulting  from  stuporose  melancholia  of  long  standing  : — 

H.  T.,  short  of  stature,  slight  iu  build,  and  thin,  was  admitted  at  the  age 
of  twenty-six.  She  is  a  married  woman,  of  steady,  temperate,  industrious  habits, 
and  Mas  suffering  from  her  first  attack  of  maniacal  excitement,  the  onset  of  wliich 
occurred  a  week  ago.  No  predisposing  or  exciting  cause  could  be  ascertained  for 
her  attack. 

Shortly  after  admission  she  became  violently  excited,  and  apparently  in  great 
terror  and  suspicion,  of  all  around.  After  a  short  remission  of  this  excited  stage, 
she  became  depressed,  apathetic,  and  torpid  in  appeai'ance.  She  would  stand  or 
sit  in  one  position  for  hours,  gazing  vacantly  before  her — nor  could  she  in  any  way 
be  roused  from  this  abstracted  state.  The  catamcnia  have  not  appeared  since  her 
admission.  Ten  weeks  after  admission,  her  mental  condition  had  so  far  improved 
as  to  permit  of  her  attending  Church  service  and  entertainments  ;  her  bodily 
health  also  was  considerably  better.  Shortly  after  this  it  is  noted  : — She  is  in  a 
state  of  profound  reverie^mental  state  apparently  one  of  painful  tension  :  fixed 
as  though  petrified  to  the  seat  or  floor,  her  gaze  is  one  iiidi(;ative  of  intense  self- 
abstraction  and  the  prevalence  of  some  delusional  idea  wliich  dominates  her  whole 
life,  and  which  now  frequently  issues,  without  any  warning,  in  sudden,  impulxlre, 
and  most  frantic  attempts  at  self-destruction,  by  throwing  herself  violently  on  the 
floor,  or  dashing  her  head  against  the  wall.  She  would  then  lapse  into  a  cata- 
leptic state,  in  which  her  limbs  might  be  made  to  assume  any  position  for  a 


STUPOU  :    PRIMARY    DKMENTIA.  157 

lengthened  period — her  aspect  trance-like,  her  expression  indicative  of  intense 
and  painful  mental  concentration  :  no  vacuity,  nor  any  appearance  suggestive  of 
dementia.  Five  months  after  admission,  the  painful  mental  state  had  subsided, 
but  there  was  much  stupor,  with,  Iiovvever,  occasional  gleams  of  intelligence — 
transient  recognition  of  her  surroundings.  She  could  not  be  induced  to  employ 
lierself ;  Avas  found  one  morning  in  a  fixed  attitude  in  the  centre  of  the  laundry 
wash-house,  and  on  being  questioned,  said  she  was  "at  the  Mi<lland  Station 
awaiting  the  down  train. "  She  was  very  pale  and  anemic — there  was  amenorrha-a. 
.Siie  now  takes  iron  and  arsenic  in  mixture:  subsequently  altered  to  iron  and  aloes. 

On  June  G,  1SS3. — Slie  cannot  bo  persuaded  to  employ  herself:  still  at  times 
assumes  fantastic,  rigid,  cataleptic  postures,  but  is  not  now  \'iolent  to  herself — 
spasmodic  outbursts  of  temper  occur,  when  she  is  aggressive  and  destructive.  Her 
expression  now  indicates  a  full  ajjpi'eciation  of  all  tliat  occurs  around  her,  and 
judging  from  it,  an  absence  of  mental  pain.  Iron  with  cantharides  and  guaiacuin 
ordered  to-day. 

June  11. — The  catamenia  have  now  appeared. 

July  23. — A  Faradaic  current  applied  to  the  head  daily  for  five  to  eight  minutes. 

July  31. — No  benefit  has  resulted  from  Faradaism  :  to-day  a  constant  current, 
from  six  to  eight  (C4aiffe's)  cells,  was  substituted,  one  electrode  to  forehead,  the 
other  to  occiput,  the  direction  of  the  current  changed  by  commutator  several 
times,  during  five  or  eight  minutes  daily. 

August  4. — Somewhat  brighter  in  mind,  cleaner  iu  her  habits,  still  idle  :  shows 
signs  of  indecency — exposing  herself,  and  on  being  reproved  threatens  to  slap  the 
officer  in  the  face.  There  is  wide  dilatation  of  the  pupils  ;  cataleptiform  positions 
are  still  assumed,  and  long  retained. 

August  9. — Continued  improvement :  catameuia  have  occurred  naturally  again  ; 
has  commenced  employing  herself  at  needlework  :  galvanism  still  continued. 

October  11. — Constant  current  discontinued  to-day:  her  attacks  of  impulsive 
violence  and  excitement,  as  also  her  cataleptic  states,  occur  frequentlj'.  Ko 
improvement  occurred  subsequent  to  that  above  noted,  and  in  June,  lSS-1,  it  is 
recorded  that  she  still  has  a  fixed  ecstatic  look,  is  undoubtedly  deluded,  sudden, 
and  dangerous.     The  case  then  assumed  the  character  of  ordinary  chronic  mania.* 

Acute  Dementia. — We  have  stated  above  that  the  extremes  of 
stuporose  states  represent  such  profound  lethargy  as  closely  to 
;simulate  the  aspect  of  genuine  dementia:  in  fact,  stuporose  melancholia 
passes,  by  almost  imperceptible  gradations,  into  unequivocal  dementia, 
and  in  several  instances,  we  observed  the  melancholic  stupor  which 
characterised  the  onset  of  an  attack  pass  into  typical  dementia. 

In  other  instances,  however,  the  reductions  are  from  the  onset  so 
profound  that  a  primary  dementia  occurs  quite  suddenly,   and   this 

*  In  connection  with  stuporose  states,  Ur.  Whitwell,  Pathologist  to  the  Menston 
Asylum,  has  communicated  to  me  certain  observations,  whilst  these  sheets  were 
passing  through  the  press,  which  appear  to  have  an  important  bearing  upon  the 
pathology  of  some,  at  least,  of  these  instances  of  stupor.  Careful  measurement  of 
the  blood-vessels  at  the  base,  by  the  graduated  cone,  leads  him  to  infer  the  presence 
of  a  congenital  narrowing  of  their  lumen,  associated  also  with  a  universal  cardio- 
vascular enfeeblement.  Dr.  Whitwell's  observations  will  appear  in  extenso  in  the 
Journal  of  Mental  Science. 


158  STATKS    OF    DEPRESSION. 

represents  the  condition  'usually  known  as  typical  acute  dementia. 
Acute  primary  dementia  lias  been  by  some  confounded  with  the 
stuporose  lonii  of  niihiiicliolia — melunchoUe  avec  stupetir :  by  others, 
with  simple  stupor,  i.e.,  suspension  of  the  intellectual  operations  apart 
from  melancholic  states,  and  not  one  of  actual  ahoUtlon  of  function. 

Undoubtedly,  however,  there  is  a  genuine  acute  dementia,  in  which 
the  patient  recovers  to  a  certain  extent,  but  invariably  exhibits  much 
impairment  of  his  mental  faculties  ever  afterwards.  It  is,  of  course, 
not  suggested  that  the  profound  torpor,  amounting  in  these  cases  to 
the  appearance  of  utter  fatuity,  represents  the  degree  of  actual 
dementia,  i.e.,  of  destruction  of  function:  much  of  this  is  truly  due  to 
simple,  though  profound^stupor — we  can  only  judge  of  the  amount  of 
actual  destruction  of  function  upon  the  patient's  so-called  recovery. 
We  lind  that  this  statement  applies  to  all  forms  of  dementia:  all  alike 
are  liable  to  a  certain  admixture  of  stuporose  states,  which  appear  to 
emphasise  the  degree  of  abolition  of  mind — but  which,  dissipated  by 
rousing  the  patient,  indicate  to  us  no  such  profoundly  inactive  con- 
dition as  we  should  at  first  sight  bo  inclined  to  predicate.  In  severe 
cases  of  acute  dementia  no  such  rousing  can  be  induced,  and  upon 
restoration  to  raoi-e  active  function,  the  mind  of  the  subject  still  fails 
to  recall  much  (if  anything  at  all)  that  has  taken  place  throughout  the 
attack. 

The  following  is  an  interesting  case  of  this  primary  dementia, 
occurring  in  a  young  girl  at  the  West  Riding  Asylum  : — 

A.  J.,  who  is  now  twenty-two  years  of  age,  was  admitted  seven  j'ears  ago  in 
a  state  of  partial  stupor.  She  had  been  regarded  as  imbecile  from  birth.  Had 
never  been  able  to  read  or  write:  although  troublesome,  she  had  not  proved 
vicious,  dangerous  to  others  or  herself,  or  of  destructive  habits.  Had  not  suffered 
from  epilepsy.  Her  family  history  was  free  from  insanity,  apojjlexj',  epilepsj%  and 
phthisis.  Patient  had  never  injured  her  head.  Quite  recently  it  was  recorded  tiiat 
she  had  become  sileut,  gloomy,  stupid,  standing  about  staring  vacantly  before  her  ; 
her  habits  were  degraded — required  compulsory  feeding.  At  times  it  was  recorded 
that  she  appeared  in  terror,[|and  behaved  as  though  she  saw  and  heard  imaginary 
objects  about  her.  Upon  admission  there  was  much  stupor:  she  remained  per- 
fectly mute  to  all  questions, 'and  her  conduct  did  not  lead  one  to  believe  that  she 
appreciated  either  spoken^ or  pantomimic  language:  a  slight  inarticulate  cry  alone 
escaped  her.  Facial  conformation  of  low  type — expression  heavj',  torpid.  She 
showed  a  slight  cataleptic^tixity  of  the  body  and  limbs  at  times:  the  limbs  were 
cold  and  bluish.  She  was  quite  helpless,  of  dirty  habits,  and  had  to  be  clothed 
and  fed. 

The  stupor  rapidly  passed  off,  and  she  Avas  found  to  be  a  lively,  good-humoured 
girl,  very  childish  and  imbecile,  however,  but  able  to  speak  in  broken  utterances. 
Became  active,  industrious,  and  cleanly  :  she  was  somewhat  boisterous  and  excitable 
in  l)ehaviour  at  times. 

In  August,  1SS2,  it  is  noted:  — She  has  become  heavy,  apathetic,  ajiparently 
demented;  is  negligent  in  her  habits,  never  speaks,  and  requires  all  her  bodily 


ACUTE    PlilMAKV    DKMKXTIA.  159 

wants  to  be  ministei'ed  to  by  othfirs;  she  slavers  at  the  mouth,  extremities  are  cold 
and  livid;  catamenia  have  not  occnrred  for  six  weeks.  Is  led  about  readily  and 
exercised. 

On  the  11th  of  September  she  suddenly  spoke  to  some  patients,  calling  them 
by  name,  and  remarked  upon  the  beauty  of  some  flowers  near  her.  She  then 
relapsed  into  her  former  heavy,  drowsy  state,  and  so  remained  until  the  2nd  of 
December,  when  she  recovered  her  speech  and  mental  powers  as  suddenly  as  they 
were  annulled,  and  immediately  began  working  in  the  wards.  She  was,  however,, 
flighty  and  excitable,  and  on  the  9th  of  this  month  it  is  noted  that  she  "is^ 
extremely  excited  and  destructive,  giving  much  trouble— is  mischievous,  dis- 
orderly, and  violent" — for  which  attack  she  was  treated  by  ^  grain  doses  of 
hyoscyamin,  and  also  by  bromide  with  Indian  hemp. 

During  the  year  1SS3,  she  had  repeated  attacks  of  stupor  which  were  charac- 
terised by  their  sudden  onset  and  rapid  relief;  but,  in  all  cases  alike,  a  stage  of 
maniacal  excitement  followed  upon  the  stupor.  In  these  attacks  of  stupor  she- 
stands  about  in  a  stooping  attitude— motionless  unless  led  ;  does  not  resist ; 
head  droops,  the  face  is  expressionless,  and  saliva  runs  from  the  partially  open, 
mouth;  the  pupils  are  widely  dilated,  the  arms  hang  helplessly,  the  hands  and 
feet  are  cold  and  livid.  She  has  the  aspect  of  one  whose  mental  faculties  are  in 
complete  abeyance.  She  remains  where  she  is  placed,  and  no  voluntary  movement 
is  initiated — moves  a  step  or  two  when  pushed,  and  there  remains  motionless  until 
again  moved  by  others.  She  never  attempts  to  feed  herself,  nor  does  she  resist  the 
efforts  made  to  feed  her,  but  swallows  the  bolus  when  introduced  into  her  mouth  : 
she  is  wholly  inattentive  to  the  state  of  bowels  and  bladder.  The  subsequent 
attack  of  excitement  on  return  of  partial  consciousness  was  invariably  of  the  same  • 
character — loud,  hilarious,  boisterous  merriment,  mischievous  propensities,  and 
occasional  vicious  conduct :  she  was  also  destructive  of  clothing,  and  wilfully 
destroyed  glass  and  ornaments.  Upon  the  reinstatement  of  her  former  mental 
health,  she  never  could  recall  any  experiences  of  her  stage  of  stupor,  although 
frequeiitly  questioned  upon  this  point.  The  last  attack  of  the  kind  occurred  on 
the  15th  of  May,  1SS5,  and  her  mental  faculties  did  not  clear  up  until  the  20th  of 
November,  a  period  of  six  months. 

In  stich  cases,  we  do  not  find  the  subject  prone  to  sudden,  Avild 
outbvirsts  of  maniacal  or  melancholic  frenzy,  such  as  we  found  pre- 
vailed in  stiiporose  melancholia — to  active  and  desperate  attempts  at 
self-destruction,  foUoived  by  as  sudden  a  lapse  into  the  stupor ose  state. 
The  condition  of  mind  is  distinct  in  the  two  affections  :  in  the  one 
(the  melancholic)  it  is  strained  and  ever  ready  to  explosive  outbursts,, 
in  the  other  (the  demented)  too  feeble  to  initiate  any  such  attempt. 

Tlie  maniacal  outbursts  characterising  the  last  case  detailed,  were- 
really  upon  the  road  towards  a  restitution  of  the  normal  state  of 
mental  health  :  as  the  stupor  lifts,  so  the  maniacal  reductions  come  to 
the  front,  ere  the  subject  is  restored  to  her  former  self  And  yet,  not 
to  her  former  self,  for  a  passage  of  her  life,  as  we  see,  is  comY)letely 
obliterated,  and  the  mind  is  a  blank  to  the  events  of  each  attack. 

The  apathetic  passivity  of  such  cases  also  contrasts  strongly 
with  the  resistance,  and  often  violent  struggling,  olfered  by  the  subject 


1*60  STATKS    OK    UKPRKSHIOX. 

of  melancholia  cum  stuj»ore.  Tlio  blank,  stu)ti(l,  idiotic  stare,  and  tlio 
artterly  demented  expression,  are  likewise  very  diflerent  from  the  aspect 
(presented  by  the  latter  afiection,  where  mental  tension  is  very  evident 
dn  the  pained  look,  wjiich  sometimes  is  varied  by  gleams  of  transient 
•t'cstasy.  Cataleptic  fixation  of  the  limbs  is  a  frequent,  but  by  no 
jneans  invariable,  iu-conipaiiiiaent  of  acute  dementia. 

Some  subjects  of  this  disease  are,  according  to  Dr.  Blandford,  in 
-incessant  movement :  "  One  girl  used  to  snap  her  jaws  together  for 
■  days  at  a  time,  and  then  changed  to  wagging  her  head  from  side  to 
^ide."     These  are  the  less  profound  instances  of  reduction. 

The  heart  is  feeble,  and  there  is  great  toi-por  of  circulation — the 
fliands  and  feet  being  cold  and  livid  to  an  intense  degree.  Such 
■jiatients  arc  utterly  negligent  in  their  habits,  they  require  feeding 
■throughout  the  attack,  and  all  their  wants  have  to  be  attended  to  by 
•others. 

The  following  instance  of  acute  dementia  of  three  years'  standing  is 
:a  remarkable  instance  of  the  relief  afforded  by  an  acute  pulmonary 
affection.  The  fact  is  well  establislied,  that  certain  acute  mental 
ailments  derive  transient  or  even,  permanent  benefit — at  times  attain 
complete  recovery — from  the  incidence  of  an  inflammatory  implication  of 
•distant  organs,  or  even  upon  the  appeai'ance  of  furunculi  or  carbuncle, 
•or  erysipelas  of  the  head  or  face.  The  case  in  i)oint  jjresents  a  parallel 
instance. 

W.  S.,  aged  nineteen,  a  gardener — of  strong  neurotic  inheritance,  his  fatlier  having 
liad  repeated  attacks  of  insanitj',  and  his  brother  being  at  present  an  inmate  of 
this  asylum — was  admitted  on  the  19th  of  June,  1885.  There  is  no  criminal  family 
iliistory.  Patient  was  spoken  of  as  a  quiet,  sober,  stead}',  well-conducted  young 
man,  always  somewhat  taciturn  until  about  four  months  preceding  his  admission, 
when  he  began  to  attend  meetings  of  the  Salvation  Army  every  niglit,  and  became 
excitable  and  preached  frequently  in  the  streets.  A  fortnight  preceding  his  admis- 
.sion,  he  talked  much  in  a  religious  strain,  was  restless,  sullen,  and  wilful:  at  a 
Wesleyan  service,  which  he  attended,  force  had  to  be  employed  to  prevent  his  rush- 
ing into  the  pulpit,  declaring  that  he  would  preach.  This  same  evening  he  left  his 
^stepfather's  house  secretly  through  the  window,  walked  to  his  brotlier-indaw's  house, 
^nd  tried  to  get  into  the  bed  where  his  married  sister  slept.  Upon  his  admission 
he  was  much  distressed:  had  stated  on  one  occasion  that  he  was  to  be  burnt:  was 
evidently  exceedingly  timid,  suspicious,  and  would  lie  sobbing  aloud,  gazing  before 
?!iim  with  distressed  exj)ression,  and  obstinately  reticent.  He  was  a  fairly  nourished 
lad — hair  brown,  irides  greenisli,  complexion  fresh,  teeth  regular,  but  palate  high- 
. arched  :  the  pupils  were  equally  dilated  and  their  reactions  normal :  the  tongue  -was 
protruded  straight  and  steadily.  The  pulse  was  of  fair  streugth,  ninety-six — the 
circulatory  and  respiratory  systems  normal.  The  urine  amber-coloured,  sp.  gr. 
1018,  acid,  free  from  deposit,  albumen,  or  sugar. 

On  the  29th  of  the  month,  i.e.,  ten  days  after  admission,  he  is  noted  as  exhibit- 
ing a  depressed  and  vacant  aspect — as  very  slow  in  all  his  movements,  and 
.maintaining  an  obstinate  silence.     He  becomes  negligent  in  his  habits,  wets  his  bed 


ACUTK    PUIMAHY    DKMENTIA.  Id 

nif;htly.  When  asked  to  protrude  his  tongue,  he  does  so;  he  feeds  himself.  He 
thus  remained  until  the  month  of  October,  when  the  stupor  became  more  pro- 
found, and  up  to  the  present  date,  sixteen  months  subsequently,  his  condition  has 
been  unchanged.  During  the  whole  of  tliis  period  he  has  presented  a  typical 
instance  of  mental  stupor,  the  former  melancholic  phase  having  quite  passed  away. 
He  sits  in  a  slovenly  stooping  attitude,  the  liead  bent  forwards  upon  the  chest— the 
legs  tliriist  out,  and  the  arms  hanging  helplessly  down.  In  whatever  position  his 
body  or  limbs  are  placed,  so  they  remain :  if  the  arms  be  extended  above  his  head, 
tliey  long  remain  so,  and  are  gradually  allowed  to  drop  to  his  side.  The  whole 
limb  thus  gi-avitates  downwards,  the  separate  flexions  of  hand  and  forearm  not 
occurring. 

Now,  in  this  case,  if  he  be  made  to  stand  up,  he  does  so  in  slouching  fashion,  and 
remains  fixed  in  any  position  we  choose  to  place  him  in :  if  pushed  along,  he  walks 
a  few  steps  only,  then  halts,  and  is  again  immobile :  if  pushed  towards  an  obstruc- 
tion, as  a  table  or  bedstead,  he  shows  his  consciousness  of  the  obstacle  by  tending 
to  veer  round  with  each  step  so  as  to  avoid  it.  If  we  raise  his  arms,  they  are  found 
to  be  heavy  and  cumbrous,  and  not  so  readily  adapted  to  varied  posturing.  There 
is  an  absence  of  that  lightness  and  flexibility  whereby  they  may  be,  so  to  speak, 
moulded  into  any  form — this  absence  of  plasticity  is  due  to  resistance,  which  is 
very  appreciable  in  our  patient's  state.  The  contraction  of  the  muscles  is  not 
resolved  or  in  any  degree  influenced  by  fi'iction,  by  kneading,  or  massage.  If,  now, 
we  place  our  patient  in  an  upright  position  in  a  chair,  and  incline  it  at  various 
angles,  we  find  that  he  adapts  himself  to  the  altered  position,  and  maintains 
his  equilibrium  up  to  a  certain  point,  when  he  allows  himself  to  fall.  His 
eyelids  are  partially  closed,  resist  opening,  and  the  eyeballs  are  convulsively 
rotated  upwards,  so  that  it  is  impossible  to  examine  the  pupils.  There  is  often, 
but  not  constantly,  rapid  clonus  of  the  eyelids,  which  can  be  arrested  by  firm 
pressure  of  the  fingers  over  the  supra-orbital  notch,  and  is  always  increased  by 
forcibly  raising  the  upper  lid.  The  face  has  always  a  most  stupid,  heavy  expres- 
sion, and  never  indicates  mental  pain  or  distress :  the  head  falls  forward  on  the  chest, 
and  resists  efforts  to  raise  it.  If  shouted  at,  he  does  not  appear  to  notice  what  is 
said,  although  he  starts  at  a  sudden  shock;  if  pinched  or  pricked  by  a  pin,  he  does 
not  flinch,  but  has  on  one  occasion  shown  evidence  of  feeling — a  tear  trickled  down 
his  cheek.  The  knee-jerk  is  exaggerated  in  both  legs.  He  makes  no  attempt  to 
feed  himself :  the  mouth  is  kept  firmly  closed,  and  the  spoon  has  to  be  forcibly 
passed  into  the  mouth,  when  he  immediately  swallows  the  bolus  of  food.  He  is, 
in  all  respects,  utterly  negligent  and  uncleanly.  This  patient  has  not  spoken  a 
word  for  the  period  of  three  years. 

The  blood,  examined  by  Gower's  hfemacytometer  and  hremoglobinometer,  gave 
the  following  results : — 

Ked  Corpuscles.  Hoemoslobin.  White  Corpuscles.  Value  per  Corpuscle. 

100  per  hffimic  unit.        G8  %  to  SO  %•        '4  per  hremic  unit.        -68  %  to  -80  %. 

He  had  remained  in  this  condition  for  exactly  three  years,  when,  one  morning, 
he  spoke  for  the  first  time,  became  mildly  excited,  and  shouted  aloud  the  names  of 
certain  patients  around.  It  is  noted  the  next  day,  that  he  sat  with  his  eyes 
open,  watching  with  apparent  interest  what  went  on  around,  that  he  asked  for 
some  bread  and  cheese,  but  would  not  reply  to  any  questions  put  to  him.  He  was 
still  at  times  cataleptic,  and  ivas  neijlirjent  in  his  habits:  "another  patient  makes 
him  laugh  by  imitation." 

This  partial  relief  was,  however,  attended  with  loss  of  flesh,  pallor,  and  debility, 

11 


162 


STATES    OF    EXALTATIDX. 


and  he  continued  for  nearly  three  months  in  this  condition,  occasionally  lapsing  into 
more  profonntl  stupor.  At  tins  date  an  abscess,  glandular  in  origin,  was  opened  in 
the  neck,  and  a  little  later,  dulness  at  the  right  base  and  increasing  debility 
revealed  pneumonic  consolidation.  He  was  put  to  bed,  and  almost  immediately 
upon  this  regained  a  more  normal  state  of  consciousness.  He  became  cheery, 
briglit,  chatty,  and  it  M'as  evident  that  he  was  rapidly  recovering  from  his  mental 
derangement.  He  was  kept  for  six  weeks  bedridden  by  his  attack  of  pneumonia ; 
but  from  the  first,  his  mind  remained  clear,  and  no  lapse  of  stupor  intervened. 

Just  prior  to  the  appearance  of.  chest  symptoms  his  weight  was  106  lbs. :  three 
months  later,  with  extra  diet  and  cod-liver  oil,  he  weighed  140  lbs.,  looked 
vigorous  and  robust,  and  was  an  active,  cheerful,  and  fairly  intelligent  ward 
helper.  He  recalls  certain  incidents  during  his  attack,  as  the  opening  of  the 
abscess  in  the  neck,  the  feeding  and  clothing  by  his  attendants :  but,  for  the  most 
part,  the  whole  three  years  are  a  blank  to  his  mind,  and  he  gives  most  hazy 
accounts  of  himself  just  prior  to  coming  to  the  asylum,  where  he  thought  he 
had  been  resideut  but  a  few  months.  The  blood  examined,  just  prior  to  his  dis- 
charge from  the  asylum,  gave  the  following  indications : — 

Bed  Corpuscles.  Htemoglobin.  "White  Corpuscles.  Value  per  Corpuscle. 

100  per  hc-emic  unit,  90  %.  '28  '90  %. 


STATES  OF  EXALTATION. 

Contents. — Maniacal  Eeductions — Failure  of  Attention — Enfeebled  Synthesis — 
Transient  Delusive  States— Exalted  Sense  of  Freedom— Impulsive  Conduct — 
Nocturnal  Crises— Seclusion  Fosters  Hallucination— Sexual  Illusions-  Stadium 
Melaucholicum — Enfeebled  Imagination— Bodily  Symptoms— Periodicity  of 
Maniacal  Phenomena— Acute  Delirious  Mania. 

Viewed  from  the  clinical  aspect,  cases  of  mental  depression  chiefly 
impress  ns  with  the  prevailing  feature  of  mental  pain  ;  although,  as 
we  already  have  seen,  mental  pain  is  by  no  means  an  essential  element 
in  states  of  mental  depression.  The  latter  term  to  us  connotes  far 
more  than  simple  melancholic  pain,  since  we  regard  all  cases  of  simple 
intellectual  torpor,  morbid  apathy,  and  states  of  simple  stupor  (all  of 
which  may  be  devoid  of  painful  emotional  states),  as  comprised  under 
the  category  of  states  of  mental  depression.  In  like  manner,  although 
we  may  take  the  prevailing  emotional  tone,  the  exuberant  flow  of 
thought,  and  the  general  objective  indications  of  maniacal  excitement 
respectively,  as  characterising  states  of  mental  exaltation,  we  must 
remember  that  any  one  of  these  indications  may  be  variably  pro- 
nounced, or  even  supjiressed.  We  should,  therefore,  carofullj'  define 
to  our  minds  the  connotations  of  these  respective  terms — exaltation 
and  depression;  and  we  shall  then  learn  that  the  more  ai-bitraiy,  nar- 
row, and  exclusive  our  definition,  the  less  I'eadily  do  we  perceive  that  the 
one  is  the  converse  of  the  other ;  and  that  tlie  freer  our  definition 
becomes,  so  as  to  embrace  all  mental  operations  within  its  limits,  the 


THE    REDUCTIONS  -OF    MANIA.  163 

more  readily  do  we  find  in  the  infinite  varieties  of  both  classes,  states 
in  the  one  which  are  the  exact  antitheses  of  states  in  the  other. 

It  is,  however,  of  far  greater  interest  to  recognise,  in  the  morbid 
process  which  underlies  these  states  of  mental  exaltation,  that  the 
process  of  reduction  is  usually  more  sudden  in  its  onset,  more  rapid  in 
its  course,  more  intense,  and  the  level  reached  always  lower  than  that 
of  simple  mental  depression.  In  states  of  mental  exaltation,  we  also 
trace  the  same  fiiilure  in  object-consciousness,  with  the  corresponding 
rise  in  subject-consciousness,  which  states  of  mental  depi-ession  present, 
but  how  difierent  are  the  features  of  the  two  viewed  in  contrast  ! 

Here  we  have  in  the  welling-\ip  of  feeling,  pleasurable  emotions 
in  place  of  painful  states ;  a  genei'al  sense  of  well-being,  exuberant 
joy,  excessive  hilaiity,  an  overflowing  of  the  spirits  in  generous 
impulses,  an  egoistic  self-confidence — all  strongly  contrasting  with  the 
grim  foreboding  of  coming  evil,  the  gloomy  aspect  of  the  present,  the 
sorrows  of  the  past,  the  sense  of  the  subject's  helplessness  before  an 
encroaching  and  malign  environment.  So  also  in  the  rapid  flow  of 
thought — disconnected,  incoherent  as  it  is — expressed  in  rapid  utter- 
ance, associated  with  restless  movement,  energetic  pantomime,  and  a 
sense  of  utter  lawlessness  (often  issuing  in  reckless  conduct),  we  have  a 
striking  contrast  to  the  sluggish  ideation,  enfeebled  imagination,  apathy, 
paralysed  energy,  and  restricted  movement  of  the  melancholic. 

Yet,  fundamentally  distinct  as  these  mental  states  would  appear  to 
be,  we  have  little  doubt  that  the  process  of  reduction  is  the  same  for 
both ;  but  in  maniacal  states  the  dissolution  is  to  a  g'reateP  depth — 
the  difi"erence  is  one  of  degree. 

All  maniacal  conditions  are  pre-eminently  distinguished  by  a  failure 
of  attention,  or  the  capacity  for  serial  thOUg"ht,  and  a  rise  of  the 
pur-ely  sensuous  in  place  of  the  intellectual  operations — in  fact,  the 
latter  ai'e  enfeebled,  and  the  emotional  elements  are  aroused ;  and,  as 
before  indicated  in  cases  of  dej^ression,  the  intellectual  sphere  presents 
the  negative,  and  the  sensuous  the  positive  results  of  the  reduction.* 

Since  seriality  of  thought  requires  high  nervous  pressure — a  high- 
tide   of  the  nervous  wave  to  force  the  ultimate  ramifications  of  the 

*  Just  as  the  sensitiveness  of  the  retinal  field  declines  progressive!}^  from  piie 
acutely  sensitive  spot  outwards,  until  impressions  received  upon  the  outermost 
peripheral  areas  are  more  and  more  dimly  perceived  and  eventually  fade,  and 
just  as  we  tend  by  concentrating  our  attentive  gaze  on  a  fixed  point  to  limit  the 
field  of  conscious  perception  and  to  jve^s  out  of  consciousness  those  obscure  faiut 
excitations  of  the  outer  field  of  vision  :  so  Mith  the  mental  field,  as  the  serial  line 
of  thought  becomes  restricted,  as  object-consciousness  fails  in  vigour,  so  there 
crowd  into  our  conscious  life  those  obscure  and  multitudinous  impressions  which 
are  always  present,  but  are,  for  the  most  part,  excluded  from  the  immediate  gaze  of 
the  mind's  eye. 


164  STATES    OF    EXALTATION. 

cerebral  cortex — so  here  in.  mania  we  must  recognise  an  ebb  of  tliis 
cerebral  tide,  corresponding  to  the  lowei-ed  plane  of  psycliical  activity  ; 
for  the  activity  which  we  recognise  in  the  excitement  of  lower  levels 
is  one  of  disorderly  nngoverned  license,  indicative  of  the  removal  of 
the  influence  of  higher  controlling  planes. 

Of  the  three  laws  of  association  of  ideas  which  regulate  our  normal 
mental  operations,  the  law  of  association  by  similarity  embraces  opera- 
tions of  a  far  more  abstract  nature  than  is  the  case  with  that  of 
association  by  contiguity,  and  the  same  may  be  said  of  tlie  latter  as 
contrasted  with  the  process  of  association  by  accident  or  incongruity. 
It  is  the  more  abstract  representative  jirocesses  of  association  by 
similarity  which  are  first  involved  in  maniacal  reductions — tlie  less 
abstract  presentative-representative  processes  not  being  so  far  involved. 
This  fact  explains  much  of  what  we  observe  in  the  maniac's  conduct ; 
his  pei'ceptions  are  crude,  and  his  notion  of  the  essential  utility  of  objects 
around  him  is  frequently  at  fault— the  result  is  often  comical,  but  at 
other  times  it  is  disastrous  to  himself  or  others.  Thus  we  may  see  such 
a  subject  trying  to  put  his  coat  on  b}'  thrusting  his  legs  into  the  .sleeves, 
mistaking  the  garb  for  a  pair  of  trousers  ;  here  we  observe  that  the 
association  by  similarity  suggests  to  his  mind  only  imperfectly  the 
utility  of  the  garment.  In  fantastic  attempts  at  decoration,  in  the 
■wanton  destruction  of  objects  around,  in  the  tearing-iap  of  clothing  and 
bedding,  in  the  swallowing  of  garbish,  and  in  some  of  the  most  repulsive 
tendencies  of  the  maniacal,  we  must  recognise  the  failure  of  conscious- 
ness implied  in  the  imperfect  operation  of  association  by  similarity, 
and  not  refer  such  acts,  as  is  so  often  done,  to  sheer  wilful  mischief. 
The  imperfect  operation  of  the  same  law  is  seen  also  in  the  remarkable 
rhyming  tendency  presented  by  some,  viz.,  that  of  stringing  together, 
in  verse,  numerous  lines  utterly  devoid  of  sense,  but  in  which  a  well- 
regulated  rhythm  pervades  the  whole,  and  each  line  accurately  rhymes 
with  its  fellow.  Numerous  instances  of  the  restricted  operation  of  this 
law  will  occur  to  any  one  familiar  with  the  vagaries  of  the  insane. 

It  is  in  this  failure  of  the  highly  representative  processes  that  we 
must  also  learn  to  trace  the  early  origin  of  those  deluded  states  to 
which  mania  and  melancholia  tend ;  for  we  may  well  see  how  by 
their  failure  sense-presentations  are  not  so  likely  to  have  their  falsi- 
fications corrected — an  appeal  to  a  higher  tribunal  is  not  permitted. 
Transient  delusions  thus  characterise  the  maniacal  turmoil  through- 
out its  history  ;  they  are  often  but  indications  of  a  want  Of  balance 
established  between  contiguous  groups  by  discharges  from  higher 
controlling  realms,  leaving,  so  to  speak,  certain  islets  "flooded  ;"  such 
pei'vei'sions  are  of  a  very  recoverable  nature.  As  contrasted  with  the 
fi.xed  perversions  of  monomania,  Griesinger  thus  alludes  to  them  : — 


TRANSIENT   DELUSIVE    STATES.  165 

"But  if  these  two  forms  in  their  extreme  degree  are  so  utterly  distinct  as 
mutually  to  exclude  the  possibility  of  mistaking  the  one  for  the  other,  still 
observation  shows  that  in  mania  itself  such  delirious  ideas  of  self-importance  are 
by  no  means  unfrequent,  whicli  certainly  ought  not  to  be  regarded  in  an  onto- 
logical  sense  as  '  fragments  of  monomania,'  as  phenomena  of  quite  another  affection 
which  in  this  case  present  themselves  in  a  very  simple  form,  but  as  the  result  of 
the  primary  mental  condition.  ,  .  .  They  {i.e.,  the  delirious  ideas)  share  in 
the  tumult  and  precipitancy  which  agitate  the  motory  sphere  of  tlie  soul-life  ; 
they  become  so  confused  in  their  hurry,  and  pursue  each  other  so  rapidly,  that 
they  have  no  time  to  l)ecome  fixed  or  to  dwell  in  the  mind."  * 

An  "  over-action  on  lower  planes,"  as  Dr.  Huglilings-Jackson  would 
term  the  state  to  wliicli  we  allude,  cliaracterises  these  maniacal  states 
in  the  intellectual  sphere,  revealing  a  profound  failure  in  object- 
consciousness.  Ideas  arise  in  extremely  rapid  sequence,  often  as  the 
mere  result  of  casual  or  accidental  association,  the  subject  being  swayed 
by  every  passing  incident.  Every  degree  of  incoherence  may  present 
itself  according  to  the  rapidity  of  the  cerebral  processes  at  fault ;  yet, 
in  all  the  simpler  forms  of  mania,  a  temporary  command  of  the  atten- 
tion can  be  obtained  by  an  authoritative  gesture,  command,  or  other 
artifice,  when  a  perfectly  coherent  statement  may  be  elicited,  the 
memory  exhibit  normal  vigour,  and  reason  momentarily  assume  her 
sway  ;  then  they  pass  back  again  into  the  wild  turmoil  of  disconnected 
ideas  and  strange  mental  combinations.  It  is  in  the  changeable, 
fleeting  nature  of  the  mental  images  that  we  hope  for  the  patient's 
complete  restoration  to  mental  health. 

It  must  not  be  imagined  that  all  states  of  mental  exaltation  imply 
the  tumultuous  career  of  ideas  above  described.  Ideation  is  always 
quickened  by  unnatural  vigour — the  images  become  more  vivid;  but  a 
superficial  coherence  may  be  observed  which  enables  the  patient  to  hold 
rational  converse,  to  employ  cogent  argument,  raillery,  sarcasm,  or 
wit.  In  the  simplest  types  of  mania,  slight  garrulity,  a  restless  move- 
ment, and  rapidly-varying  mood  may  alone  betray  the  mental 
disturbance. 

If  we  turn  our  attention  to  the  sphere  of  subject-consciousness,  we 
find  here  in  the  majority  of  cases  a  rise  of  the  pleasurable  emotions 
and  an  unwonted  sense  of  freedom,  undoubtedly  engendered  by 
the  coincident,  unrestrained  activity  dominant  in  the  intellectual 
sphere.  The  high-tide  of  the  emotional  wave  reacts  on  the  intellectual 
sphere — the  exalted  self-feeling  issues  readily  in  action,  or  begets 
with  equal  ease  notions  of  power  and  self-importance — transient 
delusive  concepts,  which  rise  as  new  creations,  answering  to  the  pre- 
vailing mood.  The  exuberance  of  feeling  usually  expresses  itself  in 
goodwill  to  all  mankind — in  a  universal  optimism,  which  often  issues. 

*  Op.  cit.,  Y>. -Ili. 


166  STATES    OF    EXALTATION'. 

in  schemes  of  philantlii'opy  as  impracticable  in  their  nature  as  they 
are  transient  in  their  duration — in  extravagant  and  ludicrous  proffers 
of  patronage  to  science  and  arts ;  or  the  mood  may  vary  from  this  to 
one  of  supreme  ari'ogance,  in  like  manner  conjured  up  by  the  ex- 
af  cerated  self-feeling ;  and  the  subject  may  announce  liimself  to  be 
some  mighty  personage,  and  assume  a  defiant,  threatening,  or  savage 
aspect.  We  observe  that  these  reductions  in  maniacal  states  bring  the 
subject  to  a  more  automatic  OP  instinctive  level ;  impressions 
received  from  without  are  liable  to  issue  in  immediate  action — mature 
deliberation  no  longer  characterises  the  mental  operations,  but  a  state 
of  exaggerated  mental  reflex;  in  like  manner,  the  animal  passions  and 
instinctive  desires,  uncovered,  as  it  were,  spring  into  life  and  show  an 
unregulated  activity — impulsive  COnduct,  therefore,  is  especially 
prevalent  in  states  of  mental  exaltation,  and  the  maniac  may  be 
destructive,  violent,  blindly  impetuous,  or  dangerously  homicidal,  or 
react  to  any  of  the  grosser  animal  passions  and  instinctive  desires  by 
which  he  is  swayed. 

Nocturnal  Crises. — The  insane  are  peculiarly  liable  to  be  afl"ected 
by  those  cyclical  conditions  which  are  recognised  in  the  healthy  in- 
dividual, and  thus  the  periods  of  waste  and  repair,  embraced  by  the 
clay's  labour  arid  the  night's  rest,  are  shown  in  their  case  also.  The 
phenomena  of  nocturnal  crises,  and  the  periodic  character  of  their 
excitement,  are  very  notable  and  well-recognised  facts.  The  daily 
routine  of  work  may  be  passed  through  in  a  quiet,  orderly  manner ; 
obedient  to  the  "law  of  the  room"  and  the  injunctions  of  the  nurse, 
tractable  and  reasonable  in  conduct,  the  insane  may  exhibit  no  outward 
indication  of  mental  anomaly  until  more  closely  examined ;  yet, 
invariably,  as  night  approaches,  they  pass  the  hours  in  loud,  boistei'ous 
excitement,  shouting,  singing,  incessantly  chattering,  replying  to 
imagined  voices,  restlessly  wandering  about,  or  beating  the  dooi's  or 
shutters  of  their  room.  During  the  day,  the  association  with  their 
fellow-patients,  application  to  theii'  various  duties,  and  the  general 
discipline  of  their  immediate  surroundings  may  have  just  sufficed  to 
engender  that  control  over  their  conduct  to  which  there  is  now  no 
incentive.  The  seclusion  and  quiet  of  their  rooms,  the  release  from  all 
imposed  reserve,  permit  of  that  wane  of  object-consciousness  wljich  is 
invariably  followed  by  a  rise  of  subject-consciousness.  This  nocturnal 
crisis  must  be  regarded  as  the  outcome  of  those  rhythmic  changes, 
which,  in  a  normal  state,  should  issue  in  sleep. 

Such  reductions,  however,  are  but  partial,  spasmodic,  and  limited  to 
psychical  processes  only — whereas  in  sleep  the  whole  excito-motor 
apparatus  is  more  or  less  deeply  involved.  In  sleep,  object-consciousness 
quickly,    even   suddenly,   succumbs;    subject-consciousness  goes  more 


NOCTURNAL    CRISES  :    HALLUCINATIONS  :    ILLUSIONS.  1G7 

sloioly,  and  the  more  profound  depths  are  not  usually  reached  for  an 
hour,  or  even  longer ;  the  reflex  excitability  of  all  the  nei-vous  centres 
(si^inal  also)  is  reduced — the  organic  functions  are  lessened.  In  these 
cases  of  nocturnal  excitement,  however,  the  effect  of  this  periodic  lapse 
of  consciousness  is  to  call  up  moi-e  turmoil  at  lower  levels;  all  those  sub- 
jective states  arising  from  epi-  and  ento-peripheral  stimuli,  or  centrally 
initiated,  become  the  subject-matter  of  the  mental  view;  all  those  dis- 
connected and  simultaneously  originating  ideas  which  crowd  the  mind, 
and  which,  in  healthy  waking  states,  are  reduced  to  serial,  orderly 
thought,  now  run  riot — and  beyond  this,  hallucinations  of  the  special 
senses  prevail. 

Seclusion  tends  to  foster  hallucination ;  this  fact,  so  well-recog- 
nised amongst  the  criminal  community  in  prison  life,  is  especially  true 
as  regards  the  insane.  It  is  to  the  existence  of  hallucinations  that  we 
must  largely  attribute  the  insomnia  and  noisy  outbursts ;  and  it  is  an 
undoubted  fact  that  many  such  cases,  judiciously  selected,  are  benefited 
by  removal  to  an  associated  dormitory,  and  thus  nights  previously 
passed  in  noisy  excitement  become  intervals  of  repose  and  quiet. 

Such  hallucinations,  often  peculiarly  vivid,  fascinate  the  mental 
vision,  and  according  to  their  nature  call  forth  corresponding  results — 
the  patient  may  be  passionate,  wild,  threatening,  and  defiant,  abject 
with  terror,  shouting  in  alarm  for  succour,  joyous,  exultant,  or  in 
boisterous  merriment ;  every  phase  of  emotional  life  may  present  itself 
as  the  hallucinations  vary,  and  he  enacts  his  little  drama  alone. 

In  general  paralysis  these  nocturnal  orgies  are  frequent — noisy  rest- 
lessness, with  or  without  hallucination,  accompanying  the  hiter  stages 
of  most  cases. 

In  many,  the  hallucinatory  phenomena  are  recognised  by  the  patient 
as  having  no  real  objective  origin,  and  yeb  they  will  be  fostered  by  the 
fascination  which  they  entail ;  especially  is  this  the  case  with  SGXUal 
illusions  which  are  frequent  in  the  female  sex,  and  which,  it  is  pro- 
bable, are  very  largely  entertained  and  fostered.  Cases  occur  where 
the  nocturnal  reductions  having  been  recovered  from,  the  patient  is 
filled  with  remorse  or  shame,  or  accuses  certain  individuals  of  criminal 
conduct,  accompanied  by  threats  of  retribution  and  violence  ;  each  night 
the  phenomena  recur,  attended  by  erotic  excitement,  and  each  returning 
morning  they  form  the  incentive  to  indignant  protest  or  violent  conduct. 

To  many  again,  the  reductions  entailing  rambling,  disconnected 
thought  and  garrulity,  are  in  themselves  a  source  of  pleasure — easily 
controlled  when  the  patient  is  brought  into  association. 

The.  exhaustion  which  often  follows  such  nights  of  excitement  and, 
possibly,  the  accumulation  of  decomposition  and  waste  products  in  the 
blood,  induce  in  many  prolonged  sleep  throughout  the  day.  , 


168  STATES    OF    EXALTATION. 

Mania. — The  incubative  period  of  mania  is  but  a  record,  in  most 
cases,  of  a  very  gradual  declension  in  mental  vigour,  not  perhaps  at 
all  apparent  to  the  friends,  but  sufficiently  evident  to  the  subject 
himself.  Intellectual  operations  become  more  laborious  than  usual, 
thought  is  sluggish  and  tends  to  wander  (attention  being  fugacious)  ; 
strange  and  unusual  lapses  of  memory  occur — the  patient  is  "absent" 
and  forgetful.  All  mental  operations  are  not  only  difficult  and 
tedious,  but  are  followed  by  weariness  and  ennui,  and  a  gloom  over- 
spreads the  mind,  for  which  there  is  often  no  obvious  cause.  At  night 
the  subject  is  restless,  obtains  but  little  sleep,  and  awakes  uni-efreshed, 
with  gloomy  forebodings,  and  a  disinclination  for  all  forms  of  exertion  ; 
in  fact,  a  frittering  away  of  nervous  energy  has  brought  him  into  the 
first  stage  of  his  malady — that  of  simple  melancholic  de])ression,  to 
which  all  the  foregoing  remarks  we  have  made  with  respect  to  simple 
melancholia  apply.  This,  the  first  stage  of  his  reductions,  is  the  stadium 
melancholicum  which  precedes  all  forms  of  mental  disease.  It  is 
not  implied  by  this  that  the  subject  necessarily  exhibits  such  a  stage 
in  all  cases — although,  undoubtedly,  many  cases  cited  of  sudden  onset 
of  excitement  without  previous  warning,  are  instances  of  a  defective 
observation  on  the  part  of  others.  The  absolutely  SUdden  onset 
of  maniacal  sijmiitoms  does  occur  at  times,  as  in  instances  of  epileptic 
insanity  from  sudden  and  severe  discharges ;  nor  is  there  any  prima 
facie  reason  for  supposing  that  such  serious  and  sudden  reductions 
should  not  occasionally  be  induced.  We  must,  however,  regard  the 
melancholic  stadium  as  the  usual  feature,  and  the  sudden  onset  of 
mania  as  quite  exceptional.  This  premonitory  stage  is  of  most  vari- 
able duration,  ranging  from  days  to  weeks,  or  from  weeks  to  months ; 
it  may  pass  off  under  favourable  circumstances,  and  again  recur  as 
former  conditions  of  life  are  resumed. 

Then  suddenly,  and  often  quite  unexpectedl}',  comes  a  marked 
transformation,  signalising  the  maniacal  reduction.  The  gloom  and 
despondency  appear  to  be  lifted  ofi" — reticence  and  brooding  are 
replaced  by  sociability  and  vivacity :  a  strange  light  gleams  in  the 
eye ;  an  animated  expression  replaces  the  pained  and  stolid  aspect ; 
the  moods  are  mobile,  and  an  exalted,  pleasurable  self-feeling  pervades 
the  subject.  His  thoughts,  no  longer  under  painful  restriction,  fiow 
in  unlicensed  freedom  and  in  unwonted  rapidity,  reproducing  the 
symptoms  of  early  alcoholic  intoxication.  The  patient  is  garrulous — 
obtrusively  so  :  talks  about  his  own  allairs ;  is  confidential  and  com- 
municative to  utter  strangers ;  is  egoistic,  makes  profuse  offers  to 
befriend  all  around  him  ;  is  energetic  in  his  movements,  incessantly 
restless,  and  rapid  in  his  utterances.  If  we  test  his  individual 
faculties,  we  may  find  his  memoiy  fairly  intact,  or  partially  obscured, 


MANIACAL    REDUCTIONS.  1G9 

upon  events  occurring  during  Lis  maniacal  attack ;  his  attention  is 
commanded  with  more   or  less  difficulty,  according  to  the  intensity 
of  the  excitement  (depth  and  extent  of  reduction),  but  in  all  simple 
forms  of  mania  it  is  readily  brought  under  control;  yet  only  to  lapse 
the  next  moment  before  the  tumultuous  flow  of  incoherent  thought. 
If  we  leave  him  to  his  own  devices,  and  listen  to  his  rambling  speech, 
we  discover  that  fragmentary  condition  of  language  which  attests  the 
want   of  coherence   of  ideas — a  weakening   of  that  synthetic  process 
which  i-enders  intelligent  and  rational  thought  possible ;  a  cohesion  of 
ideas  still  is  apparent,  but  it  is  that  of  the  trivial  associations  chiefly, 
and  suggestive  movements,  utterances,  or  other  impressions  presented 
casually  by  those  near  him,  will  often  blend  promiscuously  with  the 
subject-matter  of  his  thoughts,  in  the  most  grotesque  and  unregulated 
manner;  and,  as  we  have  before  explained,  the  serialitij  of  thought 
becomes  impossible.     Every  degree  of  incoherence  may  thus  present 
itself,    from   the    mildest  occasional   rambling,  to    utter   incoherence, 
where    speech   is    qiiite  unintelligible,  as   in   the    deepest   reductions 
of  typho-mania    or   acute    delirious-mania.      Tlie   patient   is   reduced 
to  a   more    automatic  level ;   his   actions    are    more    instinctive   than 
volitional,   just    as    his    ideation   is    more   reflex   in   its   arousal    and 
expression.      A  slave  to   every  passing  impression,   to   every   casual 
thought,  to  every  emotional  incitant,  his  conduct  is  wholly  unpredi- 
cable,   subject   to    no    rule   or   means   of  calculation.      The  maniacai 
subject  is  not  imaginative,  in  the  proper  sense  of  the  term  ;  at  times 
we  find  what  savours  of  imaginative  vigour,  but  all  such  gleams  are 
superficial,  transient,  and   accidental ;  the  strangest  combinations  of 
ideas  must  necessarily  prevail  at  times,   and  produce  this  apparent 
imaginative   turn — and    the    unexpected    scintillations    of  wit  which 
characterise  certain  maniacal  subjects.     Like  the  child,  his  imag'ina- 
tion  is  feeble  and  inchoate,  and,  like  the  child,  too,  his  flimsy  fancy 
wanders  aimlessly,  and  replaces  the   truly  synthetic,  creative  opera- 
tions of  the  imaginative  faculty.     Judgment  may  be  perverted  upon 
certain  points,  but  is  just  as  freqiiently  unafTected ;  in  fact,  the  mental 
faculties   exhibit    only   such    derangement  as  would    occur  from   the 
excessive  activity  of  the  maniacal  process — a  transient  confusion  or 
partial  suspension  due  to  the  rapid  flow  of  ideas.     By  this  we  do  not 
mean  that  the  subject  of  mania  does  not  suffer  from  delusions.     Delu- 
sions are  a  constant  feature  in  maniacal  excitement ;   but  they  are 
extremely   transient,  rapidly  varying  in  their  nature,   and  changing 
with   the    ever-changing   mood ;    their   superficiality    declares    itself 
in  their  continuous  displacement  by  fresh  delusive  ideas,  for  they  do 
not  remain  permanent,  as  in  the  false  conceptions  of  so-called  mono- 
mania.    Their   origin   can  be    attributed  only  to   the  confusion    and 


170  STATES    OF    KXALTATIOX. 

tumult  of  ideas  occurring  with  the  emotional  biickground  of  exaggerated 
^vell-being  and  unnatural  egoism  ;  in  fact,  on  the  prevailing  tone  of  the 
moment  seems  to  depend  the  character  of  the  false  belief  entertained. 
The  following  case  illustrates  what  we  have  just  said  : — 

G.  K.  L.,  aged  twenty-one,  single,  by  occui)atiou  a  dyer.  A  younj^  man  of 
moderate  height,  muscular,  pale,  and  ana;mic,  with  an  icteric  tinge  of  skin  :  a 
very  retreating  forehead.  Last  year  he  had  suffered  for  some  five  months  from  a 
.similar  attack  to  his  present  seizure.  An  uncle  of  patient's  was  depressed,  but  no 
further  clue  to  heredity  was  obtainable.  He  had  suffered  from  convulsions  during 
dentition,  but  his  health  had  proved  satisfactory  up  to  his  first  attack  of  mania. 
He  had  been  somewhat  intemperate  in  his  habits.  He  was  in  a  state  of  continuous 
mianiacal  excitement,  shouting  aloud,  singing,  laughing,  and  gesticulating  frantically. 
At  lirst  he  did  not  sleep  well,  and  was  noisy  through  the  night;  chloral  was 
given  with  good  results.  Through  the  day  he  was  boisterous  and  unruly, 
rambling  incoherently,  and  destroying  his  clothing.  He  raps  the  walls  with 
his  knuckles — calls  out  in  imperative  tones  to  imaginary  individuals  with 
whom  he  holds  converse;  but  calms  down  on  being  spoken  to  authoritatively, 
and  condescends  to  give  certain  information  respecting  himself  in  a  grandio.se 
:Style  and  a  pompous  voice.  In  almost  the  same  breath,  he  declares  himself 
to  be  the  "Prince  of  Wales — the  Prince  of  Peace — Lord  of  lords  and  King 
■of  kings;  his  mother  is  the  Duchess  of  Kent."  He  is  fully  aware  that  he  is 
in  the  West  Riding  Asylum,  and  gives  correctly  the  date  of  the  month  and  other 
particulars.  He  assumes  fantastic  attitudes,  which  symbolise  his  prevailing  feelings 
for  the  time ;  struts  about  in  pompous  style,  throws  himself  into  an  attitude  of 
wrapt  attention ;  or  with  lowering  brow  and  clenched  teeth  apes  an  aspect  of  rage 
;and  defiance ;  then,  as  suddenly,  with  a  lordly  wave  of  the  hand  and  gracious 
•smile,  he  addresses  those  around  him  by  dignified  titles,  the  very  next  instant  to 
lapse  into  the  clown  and  turn  summersaults  about  his  room.  At  one  moment  he 
announces  himself  as  General  Gordon— at  another  he  is  Sir  Garnet  Wolseley,  and 
by  tone  and  gesture  assumes  a  military  bearing.  These  rapidly  varj'ing  delusional 
rstates,  the  one  supplanting  the  other,  all  indicate  the  egoistic  sentiments  of  the 
mind,  the  overflow  of  animal  spirits,  the  superabundance  of  energy  finding  free  and 
ready  expression  in  incessant  movement,  pantomime,  and  speech.  From  the  very 
•outset,  his  habits  were  negligent  and  degraded,  and  he  \vas  early  found  to  be 
.addicted  to  masturbation;  his  gestures,  also,  and  expressions,  often  indicated 
a,  sexual  excitement.  When  referring  to  insanity  at  the  adolescent  period,  we 
shall  find  this  arrogant  and  egoistic  state  of  mind  to  be  often  associated  with  habits 
of  masturbation. 

In  the  course  of  six  months,  this  patient's  excitement  entirely  disappeared,  and 
he  was  able  to  give  a  fair  account  of  his  feelings,  athrmiug  that  he  believed  him- 
:self,  throughout  the  attack,  to  be  some  great  personage  with  military  fuuctions. 

The  exuberant  swell  of  feeling,  and  the  torrent  of  disconnected  ideas, 
iUiay  express  themselves  in  continuous  gaiTulity,  in  nois}'  chattering, 
in  threatening  and  abusive  tones,  in  laughter,  singing,  or  loud  shout- 
ing, with  coi'responding  pantomime  and  almost  ceaseless  activity ;  or 
•the  feeling  of  unusual  freedom  and  energy  may  find  relief  in  destruc- 
tive tendencies — smashing  of  glass,  breaking  of  furniture,  tearing  of 
.clothing,  or,  perhaps,  in  violent  aggressiveness. 


BODILY    SYMPTOMS    IX    MAMA.  171 

The  rapid  alternations  of  disposition  are  peculiarly  striking ;  the 
surging  of  the  emotional  wave  is  followed  by  an  ebb,  only  to  reappear 
in  other  forms,  so  that  intervals  of  calm  may  find  the  patient  even 
reticent,  despondent,  or  abjectly  miserable,  until  some  trifling  cause 
liglits  up  the  flame  afresh.  These  intervals  of  depression  ai'e  in  nowise 
difl^erent  from  the  melancholic  states ;  in  fact,  it  is  but  a  step  from  the 
maniacal  to  the  melancholic  stage.  At  tliis  instinctive  level,  the 
patient  instantly  I'eacts  to  the  most  trivial  excitant,  with  utter  dis- 
regard to  decency ;  peripheral  irritation  may  thus  induce  open  and 
shameless  masturbation,  or  nymphomaniacal  states  may  render  the 
subject  of  either  sex  repulsive  in  the  extreme.  In  like  manner — dirty, 
degraded,  negligent  habits  arise,  and  depraved  appetites  spring  into 
life.  Sensorial  disturbances,  in  the  form  of  illusions  and  hallucina- 
tions, are  of  very  frequent  occurrence  in  mania ;  and,  at  times,  it 
becomes  difficult  to  engage  such  patients  in  conversation,  so  intent  are 
they  listening  to  these  phantom  voices,  or  busy  shouting  aloud  their 
replies ;  or,  whilst  talking  to  \is,  the  rapid  tu.rn  of  the  head,  the 
hurried  gesture,  the  interposed  exclamation,  or  irrelevant  remark, 
indicate  these  sensorial  phenomena. 

Bodily  Symptoms. — Although,  in  a  certain  proportion  of  cases, 
especially  in  alcoholic  and  senile  subjects,  and  in  the  maniacal  excitement 
of  general  paralysis,  we  note  considerable  injection  of  the  vessels  of  the 
head  and  neck  with  a  sufi'used  aspect  of  the  face — the  great  majority 
of  maniacal  subjects  ujidoubtedly  exhibit  7narlced  pcdlor  of  the  face — the 
skin  generally  being  also  of  yellowish  tinge,  unctuous  feel,  and  foul 
odour.  The  pulse  is  small,  somewhat  frequent,  and  the  heart's  sounds 
are  often  mufiled.  Griesinger*  speaks  of  the  heart's  sounds  as  being 
indistinct  during  the  paroxysm  of  excitement,  and  becoming  clear 
during  moments  of  calm ;  during  the  maniacal  paroxysm  also  we  learn 
from  Dr.  ClitFord  Allbuttf  that  the  optic  diSC  iS  anasmic,  becoming, 
in  a  few  days  subsequent  to  the  attack,  sufi'used  and  oKscure.  The 
spasm  of  the  retinal  vessels,  presumably  present  in  these  cases,  appears 
to  us  of  great  importance  in  revealing  the  true  nature  of  the  maniacal 
process  as  distinguished  from  states  of  mental  depression. 

The  tongue  is  often  coated  and  foul ;  the  bowels  are  torpid ;  whilst 
the.  appetite,  sometimes  indifferent,  is  more  frequently  exalted  and 
often  insatiable.  It  matters  not  how  well  the  patient  takes  his  food — 
incessant  activity  and  continued  insomnia  are  sure  to  result  in  loss  of 
body-weight ;  in  most   instances  great  emaciation   prevails — the  face 

*  Op.  clt. ,  p.  2SS. 

t  The  Ophthalmoscope  in  Diseases  of  the  Nervous  S!/ste7n.  Dr.  Allbutfs  observa- 
tions are  based  upon  the  exanimation  of  as  many  as  tifty-one  cases  of  mania  at  the 
West  Riding  Asylum. 


172  STATES    OF    EXALTATION. 

assuming  a  pinclied  appearance,  the  featui-es  are  sliarpened,  a  dark 
areola  surrounds  the  oycs,  the  eyeballs  are  sunken,  yet  restlessly 
active  and  mobile.  The  reinstatement  of  a  well-nourished  frame  is  a 
rapid  process  cet.  par.  upon  cessation  of  the  maniacal  symptoms. 
There  is  frequent  interference  with  the  menstrual  function,  during 
the   course   of  mania.      Despite    the    incessant   motor   agitation   and 

excitement,  tlic  body  temperature  is  apyrexial  and  normal. 

Periodicity. — During  the  course  of  mauia.cal  excitement,  a  remark- 
able periodicity  is  often  noted  in  the  exacerbations  and  remissions 
which  occur.  We  have  already  alluded  to  the  nocturnal  crises  which 
are  very  prevalent,  and  we  may  now  draw  attention  to  diui-nal  varia- 
tions of  excitement  and  calm  occurring  upon  alternate  days,  and  to 
which  the  attention  of  the  nurse  is  often  attracted — an  observant  nurse 
will  often  speak  of  such  a  patient's  '^ quiet  day''''  or  his  '■'■had  day,''' 
referring  to  this  strange  alternation.  We  quite  as  frequently  find 
the  subject  alternate  between  mental  exaltation  and  depression  from 
day  to  day,  and  this  ready  transition  from  one  form  to  the  other 
appears  to  us  of  the  highest  importance  for  a  proiier  comprehension  of 
the  pathogenesis  of  these  mental  states. 

The  menstrual  molimen  is  especially  prone  to  arouse  in  these  subjects 
an  exacerbation  of  excitement,  so  that  a  monthly  periodicitj"  in  these 
maniacal  outbursts  (with  more  or  less  complete  remissions  intervening) 
is  by  no  means  infrequent.  Frequent  relapses  occur  in  certain  sub- 
jects, apparently  attributable  to  the  vicious  habit  of  masturbation — 
maniacal  reductions  and  stuporose  states  being  often  readily  incurred. 

Acute  Delirious  Mania.  —  This,  the  delire  aig'u  of  French 

writers,  represents  the  most  profound  maniacal  reductions  wjiicli  we 
meet  with,  just  as  simple  mania  connotes  the  symptoms  of  the  milder 
reductions.  The  disease  is  often  most  sudden  in  its  onset,  and 
frequently  appears  to  follow  upon  some  moral  cause — shock  or  fright. 
This,  however,  is  attributable  to  the  special  predisjiosition  of  the  subject, 
evidence  of  excessive  instability  being  in  most  of  these  cases  afforded 
by  the  history.  It  differs  from  ordinary  acute  mania  in  the  intensity 
of  the  process,  the  extreme  reductions  in  object-consciousness,  the 
absolute  oblivion  in  most  cases  to  all  around,  and  in  the  rapid  course 
and  /requeue y  of  a  fatal  termination.  It  is  quite  exceptional  for  a  case 
of  acute  mania  to  prove  fatal ;  in  fact,  \inless  the  individual  is  much 
debilitated  prior  to  the  attack — suffei'ing  from  some  exhausting  ailment, 
such  as  phthisis — or  Avhen  it  is  the  sequel  of  exhausting  ha?morrhages, 
as  after  parturition,  we  augur  well  for  our  most  wildly  -  excited 
patients.  A  case  of  uncomplicated  acute  mania  usually  means  a  certain 
and  rapid  recovery.  Not  so,  however,  in  acute  delirious  mania;  here 
the  outlook  from  the  first  is  most  ominous,  and  the  gravest  prognosis 


ACUTE    DELiniOUS    MANIA.  173 

miist  be  given.  Tlic  tongue  is  dry  and  brown;  the  lips  and  teeth 
become  covei'cd  witli  sordes ;  food  is  often  most  persistently  i-cfiised, 
and  violent  struggles  made  upon  attempting  artificial  feeding.  The 
patient  is  usually  quite  oblivious  to  our  intentions,  and  obstinately 
resists  all  we  do  for  him.  He  presents  a  pitiable  spectacle,  is  unsteady 
on  his  feet,  totters  and  sways  from  sheer  muscular  debility  and  exhaus- 
tion, and  trembles  in  his  limbs.     His  utterances  are  a  broken  strain  of 

completely  unintelligible  jargon — the  incoherence  being"  absolute ; 
the  lips  tremble,  and  speech  becomes  eventually  a  mere  babble  of  inarti- 
culate sounds,  interspersed  with  sobbing  respiration.  Sleep  is  entirely 
abolished,  muscular  wasting  rapidly  proceeds,  and  in  a  few  days  he  is 
so  prostrate  that  he  lies  helplessly  on  his  back,  unable  even  to  assume 
the  sitting  posture.  He  now  represents  the  condition  often  described 
as  typho-mania.  The  temperature  is  always  raised  more  or  less, 
sometimes  to  102°.  The  urine  may  be  scanty  or  suppressed  ;  it  mav 
pass  involuntarily,  as  do  the  stools.  If  intelligently-directed  treatment 
be  not  early  adopted,  a  rajiidly  fatal  termination  ensues ;  and  even 
under  the  most  favourable  circumstances,  the  struggle  to  bring  the 
patient  safely  through  the  storm  is  an  anxious  and  pi"oIonged  one. 
Cases  of  Delirious  Mania. 

A.  H.,  a  married  woman,  forty-seven  years  of  age,  was  admitted  after  excitement 
of  seven  days'  duration.  She  had  sufiered  from  mental  derangement  some  four 
years  ago,  attributed  by  her  friends  to  her  son's  running  away  from  his  liome;  was 
under  treatment  at  an  asylum.  A  week  ago  the  same  son  again  decamped  from 
home,  and  the  mother's  distress  culminated  in  the  present  seizure. 

No  history  of  insanity,  neuroses,  drink,  or  other  vice  in  her  ancestry.  She  was 
a  very  emaciated  subject,  of  pallid,  sallow,  pasty  complexion,  with  dilated  malar 
venules ;  there  was  a  strongly  marked  divergent  strabismus.  She  was  suffering 
from  considerable  bronchial  catarrh;  the  pulse  was  148,  regular,  but  verj"- small 
and  feeble.  There  was  extreme  ausemia — the  jaws  were  edentulous,  the  abdomen 
sunken,  the  left  hypochondrium  rather  tender,  no  splenic  enlargement.  The  genito- 
urinary system  appeared  normal. 

She  was  restless,  excited,  trying  incessantly  to  leave  her  bed,  and  talked 
continually — uttering  ejaculations  such  as,  "Oh!  my  God!  what  shall  I  do!" 
She  was  extremely  prostrate,  fainted  on  admission,  and  nourishment  liad  to  be 
forcibly  administered  by  means  of  the  stomach-tube. 

She  did  not  sleep  the  first  night,  and  next  morning  was  in  a  condition  of  acute 
delirious  excitement,  rolling  her  head  about  in  bed,  tossing  her  legs,  fumbling  with 
the  bedclothes.  All  her  utterances  were  irrational  and  completely  incoherent. 
When  asked  why  she  came  here,  she  remarked — "  To  drink  !  it  makes  great  dis- 
tinction in  the  sex  of  your  business — Follow  me — I  have  been  in  the  feminine  of 
giving  drink — Oh  !  oh  ! — I  am  receiving  gentlemen,  not  you — Remember  the  sex 
— The  feminine  discretion  of  the  place  of  my  lips."  She  refused  food,  "because  it 
is  so  abominable,  it  is  so  obstinate  to  the  effect  of  my  heart."  She  was  not 
violent,  and  her  tone  was  elated,  not  depressed. 

Essence  of  beef  with  milk,  eggs,  and  port  wine  (6  ozs.  daily)  were  ordered  ;  10 
grains  of  the  citrate  of  irou  and  quinine,  bis  die.     Two  days  subsequent  to  admis- 


174  STATES    OF    EXALTATION. 

sion  it  is  noted  : — "  Exceedingly  prostrate;  pulse  120,  very  feeble;  respirations  28. 
She  was  noisy  and  rambling  last  night,  and  is  quite  incoherent  this  morning — 
refuses  food;  bowels  torpid;  tongue  swollen  and  glazed.  Acute  delirious  condition 
has  so  far  subsided  as  to  permit  her  partially  to  understand  what  is  said,  and  to 
replj' coherently ;  compulsor}' feeding  has  still  to  be  resorted  to."  The  foUosving 
day  it  is  stated  that — "  Patient  was  more  than  usually  excited  again  last  night, 
repeatedly  sjirang  out  of  bed,  and  jumped  into  other  patients'  beds.  Slept  one 
hour  after  two  ounces  of  stimulant.  .She  remained  sleepless  and  wild  all  niglit, 
despite  a  sedative  then  given.  Has  taken  her  food  for  the  first  time  voluntarily." 
On  the  fifth  day  following  her  admission,  she  was  fairly  calm  and  rational,  having 
slept  some  four  hours  during  the  night;  but  there  was  now  noticed  a  considerable 
swelling  over  the  left  parotid  region,  so  that  she  could  hardly  open  her  mouth;  the 
lobe  of  the  ear  was  also  red  and  inflamed,  the  pulse  had  improved  in  quality. 
From  this  date,  the  patient  improved  rapidly  in  mind,  and  she  was  quite  con- 
valescent three  days  after  the  appearance  of  the  swelling.  The  latter  had  extended 
over  the  mastoid  region  and  down  the  neck,  quite  obscuring  the  angle  of  the 
jaw ;  the  integument  is  of  a  rather  congested  redness,  thickened,  and  the  swelling 
hard  and  tense;  the  left  eye  is  completely  closed  by  great  o?dema  of  the  lids; 
temperature  has  fallen  from  102'  to  100",  pulse  lOS.  There  is  considerable 
tumefaction  of  the  left  tonsil.  Suppuration  occurred  in  the  swollen  part,  and  dis- 
charge took  place  from  the  external  meatus  three  days  later.  No  relapse  of  mental 
symptoms  occurred,  and  patient  left  in  six  weeks  from  the  date  of  her  admission. 


J.  G.,  a  married  man,  aged  forty-nine,  by  occupation  a  plumber,  had  been 
treated  at  home  for  the  past  month  for  mental  symptoms  of  a  maniacal  type  ;  he 
had  violently  assaulted  his  wife  and  threatened  her  life.  His  mental  disturbance 
was  attributed  by  his  friends  to  excessive  drinking ;  one  point  was  certain — he 
had  no  insane  or  neurotic  heritage,  both  parents  had  lived  healthily  to  a  good  old  age, 
and  no  other  member  of  the  family  had  been  mentally  affected  or  had  suffered  from 
nervous  disease.  His  drinking  habits  had  extended  over  a  period  of  many  years  ; 
and  evidence  of  nervous  disease  or  mental  flaw  had  undoubtedly  been  regarded  by 
his  friends  as  but  the  result  of  intemperance.  Probably  he  had  been  deranged  for 
much  longer  than  was  stated ;  yet  he  had  w^orked  at  his  regular  occupation  up  to 
a  few  weeks  of  admission.  When  admitted,  he  was  at  once  recognised  to  be 
the  subject  of  general  paralysis  ;  he  had  pin-hole  pupils  (spastic  myosis) ;  his  voice 
and  lips  were  tremulous  ;  he  had  suffered  during  his  journey  to  the  asylum  what 
the  Relieviug-officer  believed  to  be  "a  stroke." 

But  the  important  feature  about  his  state  was  the  intensity  of  his  maniacal 
reductions  ;  he  was  evidently  in  a  profoundly  prostrate  condition,  and  was  likely 
to  sink  rapidly  from  acute  maniacal  delirium.  His  urine  was  retained,  and  had 
to  be  withdrawn  by  a  very  small  catheter,  owing  to  his  having  a  contracted  prepuce 
with  extremel3'  minute  aperture  ;  surgical  measures,  however,  were  at  once  adopted 
to  relieve  this  state.  He  could  not  stand  upon  his  feet,  but  immediately  "  doubled 
up,"  and  lay  for  the  most  part  in  a  helpless,  prostrate,  dorsal  decubitus.  Acute 
visual  hallucinations  were  constantly  present ;  he  made  continuous  snatches  with 
his  hands  as  though  to  grasp  imaginary  objects,  and  lay  muttering  utterlj'  inco- 
herent gibberish.  There  were  much  tremor  of  the  limbs,  and  muscular  jerkings 
generallj'.  Patient's  consciousness  was  so  far  obscured  that  he  failed  to  appreciate 
the  purport  of  anything  said  or  done  for  him.  Paraldehj'de  (mins.  xxx. )  was  ad- 
ministered, but  wholly  failed  to  induce  sleep;  strong  nourishment  of  milk  with  eggs, 
essence  of  beef,  and  concentrated  foods,  was  given  him,  but  with  much  difficulty, 


ILLUSTRATIVE    CASES    OF    DELIRIOUS    MANIA.  175- 

owing  to  his  resolute  resistance  and  tcrriiied  state  of  mind.  He  was  pale,  pinched, 
and  haggard,  and  continually  restless  through  the  next  day,  requiring  regular 
catheterism,  a  normal  amount  of  urine  being  each  time  withdrawn.  The  following 
night  he  obtained  no  sleep,  tossing  about  restlessly,  and  muttering  incessantly  ;  the- 
heart's  action  was  becoming  excessively  enfeebled,  his  limbs  cold,  and  his  lips  slightly 
cyanosed.  Every  precaution  was  observed,  and  small  quantities  of  nourishment- 
were  given  frequently  to  keep  his  body  warm  and  stimulate  the  circulation ;  bub 
he  died  the  following  day  from  cardiac  failure. 


Pi.  M.,  aged  forty,  married,  with  a  family  of  six  children,  had  suffered  previously 
from  slight  depression  some  ten  years  ago,  but  recovered  in  a  week,  or  so.  Her 
attack  had  began  a  fortnight  prior  to  admission.  She  had  become  restless  and 
forgetful — "put  the  bread  into  drawers,  and  things  that  should  have  gone  into- 
drawers  she  put  into  the  bread-trough;"  she  got  up  and  walked  about  restlessly 
at  night.  The  day  prior  to  her  admission,  sudden  wild  excitement  ensued ;  said 
she  would  jump  out  of  the  window,  cut  her  throat,  and  kill  her  husband.  The- 
family  history  records  no  insanity,  epilepsy,  apoplexy,  intemperance,  or  phthisis  ;. 
the  patient  had  been  a  steady,  temperate  woman,  and  had  had  a  comfortable  home 
— was  naturally  cheerful  and  talkative,  but  given  to  religious  musings.  On  her 
arrival  at  the  asylum  she  was  found  to  be  in  a  state  of  acute  delirious  mania  ;  she 
was  of  short  stature  (5  ft.  2  in.),  extremely  thin,  ill-nourished,  and  very  feeble;  her 
weight  was  78  lbs. ;  her  complexion  earthy  ;  expression  maniacal ;  the  pupils  were- 
dilated,  but  equal  and  reacted  normally ;  her  limbs  exhibited  several  recent  bruises. 
The  tongue  was  dry,  but  not  coated  or  brown  ;  the  thoracic  and  abdominal  organs- 
appeared  normal;  the  urine,  however,  contained  a  trace  of  albumen,  and  a  large- 
deposit  of  pale  urates,  but  no  sugar  ;  it  was  acid;  sp.  gr.  1032.  She  talked  inces- 
santly, was  ceaselessly  restless,  clapping  her  hands,  and  rolling  about  the  bed ;  she 
generally  kept  her  eyes  shut.  Her  language  was  mostly  incoherent,  rarely  having' 
reference  to  her  surroundings;  and  she  repeated  each  sentence  twice  or  oftener 
before  uttering  another.  Her  utter  incoherence  may  be  illustrated  by  the  following 
specimen  : — "  I  '11  let  you  save — The  devil — If  it 's  for  your  sake — The  devil — I  'IL 
try  you  once  more — His  own  son — I've  known  another — They  never  will — I'm  dead 
long  since— I'm  lost —They  won't  let  me— The  devil— Another  song — A  poor  old 
woman — The  devil — I  knew — I  should  like  it — Save  a  hundred  — He  's  lost — You're 
saved — A  palace— I  'm  dead  long  since — Her  own  father— Hundreds — Lord  help  me- 
— They  've  brought  another  in — You  've  lost  him — This  is  a  chariot — It 's  my  own^ 
son — I  won't  answer,  because  they  won't  save  me — I  make  such  a  noise,  because 
you  've  saved  so  many — They  've  driven  me  mad — Why  haven't  you  resisted  when  I 
should  be  in  a  palace,  you  have  thousands — When  I  shall  be  in  a  palace — I  've 
saved  hundreds,  save  poor  old  woman — I  've  hundreds — Why  didn't  you  save  me 
when  I  'm  lost. "  She  did  not  strike,  nor  show  hostility  beyond  resisting.  A 
liberal  diet  was  ordered  with  3  ozs.  of  whisky  daily,  and  20  grains  of  chloral  at 
night.  The  following  day  it  was  reported  that  she  had  slept  after  the  chloral  ; 
was  still  incessantly  restless,  but  not  so  talkative  ;  clapped  her  hands,  and  buried 
her  head  in  the  bedclothes. 

Each  night  she  was  restless  until  chloral  was  ordered,  when  she  slept  several 
hours,  and  awoke  far  less  maniacal,  not  so  talkative  ;  took  food  well ;  stayed  in 
bed.  In  nine  days  after  admission  she  had  become  obstinate  about  her  food,  and 
had  to  be  fed  by  the  tube ;  her  consciousness,  however,  was  less  obscured,  and  she 
recognised  nurses  and  doctors ;  her  language  was  less  unmeaning,  she  was  less 
delirious,    but  still  deluded,   and  at  times  very  incoherent.      Thus,   she   would 


17G  THE    EXPLOSIVE    OR    FULMIXATINO    PSYCHOSES. 

exclaim:  "(Jod  is  in— They're  watching,  ami  they've  broke  my  Ijrain— I  want  your 
wife."  Slept  well  witli  chloral.  The  .secoiul  week  after  adnjis.sion,  it  is  noted  — 
"  Patienfs  mania  has  lost  its  delirious  character  ;  slie  now  lias  the  lixed  delusion 
that  her  food  is  poisoned  ;  declares  that  poi.son  lias  heen  put  into  it,  and  that  is 
wliy  she  refuses  it.  Asserts  that  slie  has  plenty  of  relatives,  but  they  (the  nurses) 
keep  locking  them  up.  Calls  out,  '  Charlie,  Mr.  Haggas,  &c.'  Struggles 
violently  when  fed  ;  is  abusive  and  hostile."  At  the  end  of  the  following  week  she 
was  much  calmer,  slept  without  sedative  ;  was  fed  by  the  spoon,  and  had  lost 
most  of  her  hostility  ;  still  remained  deluded,  declaring  that  her  aunt  was  present. 
Four  days  later  (twenty-five  days  after  admission)  we  find  her  convalescent ;  the 
mania  has  passed  off;  she  is  calm,  and  occupies  herself  with  sewing;  appears  to 
have  lost  her  delusions  and  hallucinations,  and  recognises  their  nature  ;  is  a  little 
unreasonable  in  wanting  to  return  home  at  once.  Takes  food  well,  ami  sleeps 
without  sedative.  A  few  days  later  she  became  slightly  despondent,  expressed 
the  delusion  that  she  Avas  confident  some  injury  would  be  done  to  her  at  night, 
and  believed  that  the  patients  abused  her.  This  sliglit  relapse  passed  away 
rapidly  ;  she  made  steady  and  satisfactory  progress,  and  left  recovered  within  two 
months  of  her  admission. 

FULMINATING  PSYCHOSES. 

Contents. — Uniform  and  Partial  Denudations— Defective  Control— The  Neurotic 
and  Criminal  Subject— Nature  of  Impulsive  Insanity- Insane  Homicidal 
Impulse— Existence  of  Aura— Epigastric  Aura— Uncovering  of  the  Brute 
Instincts— Relief  of  Mental  Tension- Illustrative  Cases— Suicide  in  Homicidal 
Subjects— Etiolo^'y-Effect  of  Physiological  Cycles— Epilepsy— Masked  Epilepsy 
—Alcohol  and  Impulsive  Insanity— The  Mimetic  Tendency— Suicidal  Impulse. 

The  dissolutions  of  the  nervous  system  which  issue  in  insanity  by 
no  means  reduce  the  subject  to  pre-existent  levels  of  mental  life  corre- 
sponding in  all  respects  to  former  stages  of  evolution ;  the  denuda- 
tion, to  use  an  apt  term,  is  by  no  means  uniform,  so  that  the  mental 
wave  recedes  along  the  whole  line  of  its  former  advance.  Such  a 
uniform  recession  does  occur  in  physiological  senescence,  and  is  still 
more  pronounced  in  the  prematui-c  decay  of  senile  dementia;  but,  in 
most  forms  of  insanity,  the  denudation  is  a  localised  one,  or,  at  all 
events,  begins  in  many  separate  areas,  and  the  resulting  mental  dis- 
turbance is  wholly  unlike  any  of  the  results  of  a  uniform  physiological 
denudation.  The  general  results  also  will  vary  with  the  intensity  and 
rapidity  of  the  diseased  process,  and  the  factors  so  often  insisted  upon  by 
Dr.  Hughlings-Jackson  in  his  studies  of  convulsive  diseases  must  also  not 
be  neglected  in  considering  the  less  acute  processes  of  mental  disease. 

It  is  by  these  partial  denudations  that  we  seek  to  explain  the 
incongruous  results  of  tlic  dLseased  process  and  the  overbalance  of 
faculties  so  characteristic  of  mental  disease.  At  no  stage  in  the 
history  of  insanity,  except,  perhaps,  the  senile  forms,  do  we  find  the 
man  altoffethcr  reduced  to  the  mental  state  of  childhood — a  7)?«s  or 
minus  quantity  ever  prevents  an  exact  parallel  being  drawn,  so  that 


PARTIAL    DEXUDATIOXS  :    DEVELOPMENTAL    DEFECTS.  177 

we  readily  distinguish  such  auonialous  reductions  from  tlie  results  of 
a  xmiform  physiological  or  pathological  denudation.  Certain  features 
which  characterise  the  mental  life  of  the  child  spring  into  obvious 
prominence  in  the  adult  subject  of  mental  disease.  The  infantile  mind 
is  above  all  things  characterised  by  the  lack  of  control — its  instincts, 
passions,  desires,  actions,  all  alike,  exhibit  in  a  high  degree  a  want  of 
inhibitory  restriction,  and  the  further  development  through  childhood 
and  youth  to  adolescence  and  adult  age  is  a  recoi'd  of  the  slow 
progressive  superposition  of  controlling  centres.  iSTormal  mental 
development  is  specially  characterised  by  this  uniform  and  progressive 
establishment  of  self-control  (so  to  speak)  upon  higher  and  still  higher 
levels;  but,  just  as  we  get  in  the  dissolutions  of  disease  2J(f''^tial  de- 
nudations— so  here,  in  the  progress  of  mental  evolution,  we  meet  with 
developmental  phases  of  a  monstrous  chai'acter,  presenting,  not  the 
normal  uniformity  of  level,  but  the  bizarre  irregularities,  exaggerated 
here  and  defective  there,  which  signalise  so  frequently  the  neurotic 
heritage  of  the  subject.  Defective  control  over  certain  animal  passions 
and  instinctive  desires  (often  associated  with  an  intense  staccato 
restriction  over  others,  amounting  to  a  morbid  hyper-sensitiveness)  is 
a  peculiar  characteristic  of  such  predisposed  subjects  3  whilst  a  still 
more  universal  defect  of  the  inhibitory  faculty  is  illustrated  by  the 
criminal  class  of  the  community.  The  reductions  of  mental  disease, 
therefore,  will  move  readily  find  their  parallel  in  the  vaiious  anomalous 
developmental  phases  of  the  neurotic  subject,  or  in  the  extremes  of 
inhibitory  defect  presented  by  the  criminal,  rather  than  in  earlier 
stages  of  the  healthy  and  normally-developing  brain,  and  our  studies 
of  these  developmental  types  should  facilitate  our  comprehension  of 
the  varied  reductions  of  insanity. 

Much  may  be  said  of  the  ill  eflects  of  injudicious  training  of  the 
mental  faculties  of  the  young  ere  they  have  attained  an  age  when 
such  faculties  should  be  called  into  operation ;  and  we  quite  agree 
with  Dr.  Cloiiston  that  different  brains  attain  their  power  of  control  at 
different  ages,  and  we  also  have  seen  "  many  children  whose  anxious 
parents  had  made  them  morally  hypersesthetic  at  early  ages  through  an 
ethical  forcing-house  treatment;"  but  we  opine  that  all  pronounced 
instances  of  the  kind  are  neurotic  subjects,  as  in  the  case  of  the  little 
boy  of  four  mentioned  by  him,  who  "  was  so  sensitive  as  to  right  and 
wrong,  that  he  never  ate  an  apple  without  first  considering  the  ethics 
of  the  question  as  to  whether  he  should  eat  it  or  not" — yet  who  was, 
at  the  age  of  ten,  "the  greatest  imp  I  ever  saw,  and  could  not  be  made 
to  see  that  smashing  his  mother's  watch,  or  throwing  a  cat  out  of  the 
window,  or  taking  what  was  not  his  own,  were  wrong  at  all."'*    What 

*  Op.  cit.,  p.  311. 

12 


178  THE    FULMINATING    PSYCHOSES. 

we  specially  insist  upon  here  is  the  fact  that  the  subject  presenting 
such  mental  distortions  is  not  the  product  of  a  vicious  educational  code 
so  much  as  the  victim  of  an  organised  neurotic  heredity ;  and  that  we 
should  in  these  developmental  forms  learn  to  recognise  features  com- 
mon to  them  and  the  reductions  of  mental  disease.  So  also  as  regards 
the  true  criminal  type,  the  difficulty  of  drawing  any  clear  line  of 
demarcation  between  crime  and  insanity  is  well  recognised  ;  certain 
forms  of  insanity,  more  especially  the  so-called  "moral  insanity," 
presenting  peculiar  difficulties  to  our  arriving  at  a  conclusion  as  to  the 
decree  of  criminal  responsibility  involved  in  the  case.  Nor  need  this 
fact  surprise  us,  since  the  one  presents  us  with  partial  developmental 
arrests  at  levels  to  which  tlie  brain  of  the  insane  must  frequently 
become  reduced ;  what  must  always  be  kept  in  mind  is  the  fact  that 
the  one  is  the  outcome  of  a  developmental  failure,  or  vice,  the  other  is 
a  genuine  dissolution. 

All  acute  forms  of  insanity  are  peculiarly  characterised  by  this  loss 
of  control.    We  recognise  it  in  the  failure  of  attention  and  the  inco- 
herent flow  of  ideas  expressed  in  rambling  speech,  in  the  unrestrained 
passions,   varying  moods,   incessant  movement,   gesture,   and  all  the 
outrageous  conduct  of  the  maniac ;  but  it  is  not  in  these  universal  and 
complex  disturbances  of  faculties  that  we  find  the  symptoms  of  "im- 
pulsive insanity,"  as  generally  understood  by  that  term.     There  are 
mental  aifections  in  which  the  chief,  nay,  the  sole  discoverable  feature 
is  this  failure  of  inhibition  exhibited  in  ungovernable,  sudden  imp\ilse, 
and   in   entirely    unrestrained    conduct,   whilst   the    intellectual    and 
emotional  spheres  remain  wholly  or  only  in  part  xmafiected.     It  is  in 
this  freedom  of  the  affective  sphere  of  mind  from  implication,  and  the 
purely  impulsive  nature  of  the  act,  that  we  must  learn  to  recognise  the 
genuine  impulsive  insanity,  as  understood  by   older  writers.     Both 
Pinel  and  Esquirol  at  first  doiibted  the  existence  of  pure  insane  im- 
pulse apart  from  intellectual  flaw  or  delusion;  and  many  authorities 
of  repiite  have  since  their  day  considered  the  doctrine  a  dangerous  as 
well  as  a  fallacious  one ;  yet  eventually  Pinel  and  Esquirol  asserted 
the    existence   of  this   tei-rible   malady,    and   painted    its   distinctive 
features  in  uo  uncertain  colours.     Either  there  is,  or  there  is  not,  such 
a   disease  as  impulsive  insanity ;  and  we  must  remember  that  our 
denial  of  its  existence  carries  with  it  the  implication  that  the  impulsive 
conditions  which  we  recognise  in  a  minor  degree  in  healthy  physio- 
logical  states,    such    as   the    almost    irrepressible    desire    to    break  a 
delicate  glass  globe  held   in  the   hand,   and   many  other  similar  ex- 
periences which  we  are  all  familiar  with,  cannot  arise  in  an  absolutely 
uncontrollable  form  as   the    result   of  pathological    disturbance.      It 
may  appear  to  the  student  an  unnecessary  refinement  to  insist  uj^on 


IMPULSIVE    AND    MORAL    INSANITY:    HOMICIDAL    IMPULSK.  179 

this  distinction,  but  a  moment's  consideration  will  assure  him  that 
the  distinction  is  one  of  vital  import,  not  from  its  scientific  bearing 
only,  but  more  especially  from  its  medico-legal  aspects. 

The  lawyer  is  naturally  suspicious  of  the  existence  of  this  form  of 
insanity,  and  is,  very  properly,  guarded  in  his  acceptance  of  the 
doctrine  which  carries  with  it  such  far-reaching  results ;  he  perceives 
the  difficulty  of  distinguishing  between  what  is  and  is  not  controllable 
— between  an  insane  impulse  and  the  outcome  of  criminal  volition ; 
and  he,  moreover,  perceives  the  difficulty — :nay,  the  impossibility — of 
recognising  its  existence,  and  at  the  same  time  reconciling  it  with  the 
legal  criterion  of  responsibility  :  and,  lastly,  he  must  recognise  that 
the  admission  of  this  fact  throws  on  the  medical  witness  the  full 
responsibility  of  defining  what  is  and  what  is  not  of  the  nature  of  aii 
incontrollable  impulse. 

Great  as  may  be  the  difficulty,  in  many  cases,  of  clearly  distinguishing 
between  the  blind  incontrollable  impulse  of  the  insane,  and  the  rash, 
impetuous  act  of  the  responsible  criminal,  we  must  not  shrink  from  the 
imperative  duty  of  affirming  the  existence  of  this  form  of  insanity  if 
our  clinical  experience  justifies  the  belief,  so  momentous  are  the 
conseqiiences  embraced  by  its  acceptance  or  rejection. 

In  insisting  upon  such  a  distinction,  we  must  not  forget  that  it 
is  more  or  less  an  arbitrary  one — that  nature  imposes  no  such 
absolute  line  of  demarcation  between  what  we  elect  and  what  we  do 
not  elect  to  the  dignity  of  morbid  types ;  that  in  reality,  one,  or  a  few, 
or  many  of  the  mental  faculties  may  be  deranged,  and  in  all  possible 
degrees  of  intensity,  and  so  forms  of  impulsive  insanity  may  merge 
into  forms  characterised  by  intellectual  or  emotional  disturbance ; 
and  vice  versd,  intellectual  impairment  with  delusion  may  merge  inta 
the  typical  forms  of  impulsive  insanity,  exhibiting  every  shade  of 
transition  from  the  one  to  the  other  type.  What  is  of  still  further 
import  is  the  fact — ^which  clinical  experience  very  strongly  emphasizes 
— that  alternations  of  pure  impulsive  insanity  and  forms  of  intellectual 
or  moral  insanity  occur  in  many  insane  subjects. 

Nature  of  the  Insane  Homicidal  Impulse.— In  the  first  place, 

we  should  note  the  causeleSS  or  motiveleSS  nature  of  the  act;  the 
impulses  arise  wholly  apart  from  any  incentive,  delusional  or  other- 
wise, nor  is  the  victim  able,  in  the  great  majority  of  cases,  to  trace 
any  connection  between  any  pre-existing  emotional  or  intellectual 
phase,  and  the  onset  of  the  insane  impulse.  Its  irrelevancy  to  sur- 
rounding circumstances  is  in  itself  so  characteristic  a  feature,  that  the 
subject  invariably  insists  strongly  ixpon  this  fact.  Suddenly,  amidst^ 
it  may  be,  the  pleasures  of  the  family  circle,  or  at  the  moment  of 
devotional  exercise,  to  the  intense  horror  of  the  subject,  the  morbid 


180  Tin:  FiLMixATiXf;  psychoses. 

feeling  suggests  itself  without  any  obvious  provocation  (like  a  phantom 
demon),  and  requires  all  his  efforts  to  disjjcl  it.     The  horror  of  the 
position  will    often    drive    the    sufferer   to    a   free    confession    of  his 
state,  and  to  urgent  entreaties  for  protection  against  such  unbidden 
mysterious  impulses,  as  numerous  cases  attest ;   but  instances  occur, 
where  the  unfortunate  subject  has  struggled  for  years  with  his  in- 
firmity, and  never  revealed  his  deadly  secret  until  compelled  to  do  so 
upon  the  commission  of  some  desperate  act.*     The  motiveless  nature 
of  such  acts  may  be  called  in  question,    and  grave  suspicion  be  ex- 
pressed, from  the  admitted  difficulty  of  always  assigning  a  consistent 
motive  even  for  the  acts  of  the  sane;  but,  just  as  readily  as  we  may  err 
in  imputing  no  motive  to  an  act  when  such  is  not  clearly  obvious,  so, 
we  may  even  more  easily  fall  into  the  opposite  error  of  assigning  a 
wrong  motive  to  an  insane  impulse,  influenced  by  accidental  circum- 
stances in  which  the  sul)ject  happens  to  be  placed.     The  motiveless 
nature  of  the  morbid  impulse  is  forcibly  illustrated  by  cases  in  which 
the  subject  suffers  from  such  feelings  when  no  one  is  near,  or  at  the 
moment  of  awaking  from  sleep ;  for,   as  in  the   case    of  the  suicidal 
impulse   (an  impulse  which  is  equally  transient),  the  commission  of 
the  fatal   act  is   often  averted  by  the   absence  of  opportune  means ; 
so,   in  the  homicidal  impulse,  the   morbid   energy  is   dissipated  and 
the  murderous  act  averted  by  the  absence  of  the  object. 

In  the  second  place,  we  must  note  the  prodromal  indications  and 
accompaniments  of  the  insane  impulse  so  far  as  they  are  afforded  by 
subjective  and  objective  indications.  The  subjective  accompaniments 
vary  considerably  in  different  cases  ;  in  many,  the  cerebral  discharge 
which  initiates  the  impulse,  is  productive  of  a  g'enuine  aura  such  as 
often  precedes  the  epileptic  convulsion.  The  morbid  sensation  is  often 
peripherally  referred,  is  of  sudden  accession,  and  may  rapidly  pervade 
distant  parts  of  the  body.  Thus  in  the  case  of  one  unfortunate  victim 
{Reg.  V.  Mountain),  we  were  informed  that  an  intense  burning  heat 
suddenly  seized  him  in  the  epigastrium  and  was  rapidly  transferred  to 
the  throat,  accompanied  by  a  sense  of  constriction  and  urgent  thirst, 
upon  which  the  homicidal  fury  arose,  and  momentarily  bereft  him  of 
all  control.  Others  complain  of  colicky  pains,  a  sense  of  heat  in  the 
abdomen  or  chest,  headache,  restlessness,  loss  of  appetite,  and  lowness 
of  spirits  (r«v/^ort),  of  sensations  referrible  to  the  head,  "flushings 
of  blood  to  the  brain,''  a  sense  of  constriction  or  tightening,  as  of  a 
ligature,  round  the  scalp,  or  a  feeling  as  if  a  cold  fluid  were  poured 
upon  the  head  and  along  the  spine.  Dr.  Skae,  in  his  Annual  Reports 
for  1866  and  1868,  describes  a  well-marked  aura  as  preceding  homicidal 

*  See,  on  this  point,  Drs.  Buckwill  and  Take,  op.  cit.,  p.  2GS. 
i  Med.  Jurisprudence,  vol,  11.,  p.  553. 


THE    EPirJASTRIC    AURA    AND    HOMICIDAL    IMPULSE.  181 

impulse.  In  certain  other  cases  a  definite  hallucination  of  the  special 
senses  may  be  tlie  immediate  forerunner  of  the  homicidal  impulse. 
The  connection  of  these  phenomena  with  epileptic  discharges  is  often 
apparent  in  such  subjects,  and  the  following  case,  quoted  by  Maudsley 
from  Mai'c,  seems  to  indicate  the  repression  of  the  impulse  by  the 
arresting  of  the  aura  : — 

"Mr.  Pv.,  a  distinguished  chemist  and  poet,  of  a  naturally  mild  and  sociable 
disposition,  placed  himself  under  restraint  in  one  of  the  numons  cle  santii  of  the 
Faubourg  St.  Antoine.  Tormented  with  an  homicidal  impulse,  he  prostrated 
liimself  at  the  foot  of  the  altar,  and  implored  the  divine  assistance  to  deliver  him 
from  the  atrocious  propensity,  of  the  cause  of  which  he  could  give  no  account. 
When  he  felt  himself  likely  to  yield  to  the  violence  of  it,  he  hastened  to  the  head 
of  the  establishment,  and  requested  him  to  tie  his  thumbs  together  with  a  ribbon. 
This  slight  ligature  was  sufficient  to  calm  the  unhappy  P^.,  who  subsequeotly 
endeavoured  to  kill  one  of  his  friends,  and  finally  perished  in  a  fit  of  maniacal 
fury." 

The  epigastric  aura,  followed  by  spasm  of  the  throat  and  intense 
thirst,  alluded  to  above  in  one  case,  has  been  noted  in  other  subjects  ;  * 
it  is  of  interest  as  indicating  a  primary 'disturbance  of  the  vagus,  and 
as  giving  rise  to  the  most  intense  and  massive  feelings  of  organic  life, 
which  in  the  brute  arouse  the  most  ferocious  instincts. 

Thus,  Professor  Bain  says— "  They  (the  feelings  of  inanition  and  thirst)  are 
far  more  intense  than  mere  nervous  depression,  and,  therefore,  stimulate  a  more 
vehement  expression  and  a  more  energetic  activity.  Even  when  not  rousing  u]> 
the  terror  of  death,  they  excite  lively  and  furious  passions.  The  unsophisticated 
brute  is  the  best  instance  of  their  power."  And  again,  "There  is  something 
intensely  kindling  in  the  ay)petite  of  carnivora  for  food,  which  rises  to  fury  when 
the  flesh  is  scented  out  and  begins  to  be  tasted,  "f 

The  association  of  these  organic  sensations  with  the  springing  into 
life  of  the  brute  propensities  in  the  human  subject  is,  we  take  it, 
a  suggestive  fact.  Certain  objective  indications  of  the  morbid  process 
are  also  occasionally  afforded,  chiefly  of  vaso-motor  origin — intense 
pallor  may  precede  the  act,  or  the  face  may  become  suffused,  and  a 
copious  sweat  break  out  over  the  body  as  the  impulse  is  resisted  and 
subsides ;  the  heart  usually  shows  excited  action,  and  the  arteries  of 
the  neck  and  temples  pulsate  violently. 

The  intensity  of  the  morbid  process  is  further  indicated  in  the  utter 
loss  of  self-control.  "  Everything  passes  out  of  mind,"  said  one  such 
unfortunate  subject  to  us,  "  except  the  one  thing  I  wish  to  accomplish 
— I  can  think  of  nothing  but  the  desire  to  kill  some  one."  The  one 
burning  idea  prevails  to  the  exclusion  of  all  others  at  the  height  of  the 

*  See  a  case  by  Piuel  quoted  in  Dr.  Maudsley's  ResponmhUittj  in  Mental  Disease, 
p.  141. 
t  The  Senses  and  the  Intellect,  Alex.  Bain,  pp.   1*26  and  '2o3. 


182  THE   FULMINATING    PSYCHOSES. 

attack,  and  is  (in  all  respects,  as  Maudsley  has  insisted)  "  a  convulsive 
idea  springing  from  a  morbid  condition  of  nerve-element,  and  com- 
parable with  a  convulsive  movement."  *  In  other  respects  the 
condition  shows  its  kinship  to  the  convulsive  neuroses,   viz.,  in   the 

immediate  relief  atTorded  by  the  accomplishment  of  the  act,  or 

the  dissipation  of  the  morbid  energy  in  otlicr  directions  ;  like  all 
transient  nervous  discharges  from  the  cortex,  the  associated  mental 
tension  is  instantly  relieved  thereby.  Yet,  it  must  not  be  forgotten, 
that  the  impulse  is  in  many  instances  successfully  resisted ;  and  that 
the  early  history  of  many  cases  of  homicidal  mania  is  one  of  a  long- 
continued  and  secret  .struggle  of  the  victim  against  the  morbid  feelings 
which  create  in  his  mind  a  dread  and  a  horror  indescribable.  Fully 
recognising  the  atrocious  nature  of  the  crime  to  which  he  seems 
impelled,  he  is  in  constant  dread  lest  in  some  weak  moment  his  power 
of  resistance,  already  enslaved,  should  wholly  succumb  in  the  frenzy 
of  the  seizure.  Instances  have  occurred  where  this  struggle  was 
carried  on  for  years — thus  in  the  case  of  Reg.  v.  Mountain  the  prisoner 
admitted  the  existence  of  such  insane  impulses  for  a  period  of  ten 
years  prior  to  the  murder,  the  exceptional  atrocity  of  which,  with 
other  related  circumstances,  make  it  worthy  of  note  here. 

The  prisoner  was  a  young  man,  aged  thirty-two  years,  of  undoubted  neurotic 
heritage  ;  his  mother,  maternal  grandmother,  and  maternal  aunt  had  been  insane  ; 
his  maternal  uncle  had  cut  his  throat,  and  his  brother  was  of  feeble  intellect. 
The  maternal  aunt,  who  was  under  our  observation  for  years,  was  the  .subject  of 
suicidal  impulses,  had  tried  on  several  occasions  to  strangle,  to  hang,  or  to  drown 
herself,  as  the  result  of  imperative  feelings  distinctly  arising  from  the  group  of 
organic  sensations.  The  unfortunate  subject  of  such  ancestral  frailty  liad  always 
been  timid  and  imnaturally  suspicious  ;  but  no  decided  delusional  })hase  liad  been 
observed  at  any  time  until  a  few  months  preceding  the  murder,  and  then  only 
as  the  immediate  outcome  of  drink.  Ten  years  prior  to  the  event  in  question, 
he  first  became  subject  to  the  peculiar  sensations  which  we  have  already  referred 
to,  and  which  were  invariably  the  forerunner  of  intense  homicidal  impulses  ;  they 
almost  invariably  occurred  at  times  when  he  was  alone,  and  he  would  pace  wildly 
up  and  down  his  room  to  "work  the  feeling  down;"  and  often  he  has  rushed 
from  the  house  where  his  aged  mother  and  servant  lived  when  he  felt  the  feeling 
arising  lest  he  should  not  be  able  to  resist  the  murderous  impulse.  He  had 
struggled  against  these  feelings,  and  "  prayed  to  be  delivered  from  them"  in  agony 
of  mind  without  success  for  j'ears.  They  were  increasing  in  intensity,  and  to 
arid  to  his  misery  his  natural  nervousness  and  suspicion  were  also  more  prominent. 

His  mother's  attack  of  insanity  some  years  previously,  and  his  aunt's  state  (when 
he  had  visited  at  the  asylum),  constantly  preyed  upon  his  mind,  and  engendered 
the  feeling  that  he  would  become  insane.  He  had  kept  his  dangerous  feelings 
and  propensities  a  profound  secret,  so  that  his  closest  acquaintances  had  failed 
to  recognise  any  indications  of  his  real  condition  until,  latterly,  when  he  gave 
way  to  drinking  ;  and  then  it  was  observed  that  very  small  quantities  of  alcohol 

*  Op.  cit.,  p.  156. 


CASE    OF    REfJ.    r.    MOUNTAIN.  183 

produced  grave  mental  disturbance,  characterised  by  persistent  delusions  of 
persecution  and  errors  of  identity.  On  two  occasions  he  suffered  from  genuine 
attacks  of  maniacal  excitement,  but  of  transient  duration  only.  As  a  natural 
result  of  tlicsc  intemperate  habits,  his  former  symptoms  became  further  intensified ; 
yet,  up  to  the  evening  of  the  murder  (except  when  under  the  influence  of  drink), 
no  intellectual  disturbance  was  recognised  by  his  friends.  On  this  evening,  after 
taking  stimulants  freely,  he  locked  his  mother  and  the  servant  girl  in  a  room  to- 
gether, and  in  the  most  brutal  and  atrocious  manner  attacked  his  mother,  kicking 
her  to  death,  and  causing  the  most  horrible  mutilation  of  the  body,  keeping  the 
girl  at  arm's  length  by  a  loaded  pistol.  For  five  hours  this  brutal  violence  was 
continued,  he  meanwhile  affording  abundant  evidence  of  a  deluded  state  of  mind 
by  his  conduct  and  utterances.  His  subsequent  condition  upon  arrest  was  con- 
sistent with  an  attack  of  mania-a-potu.  Subsequent  to  his  recovery  from  the 
alcoholic  delirium,  he  had  experienced  a  return  of  homicidal  impulses  in  prison, 
a  man  wlio  slept  in  the  same  room  having  nearly  been  a  victim  to  his  murderous 
frenzy.  The  prisoner  was  considered  irresponsible  at  the  time  of  the  murder 
on  the  ground  of  insanity,  and  was  ordered  to  be  retained  during  Her  Majesty's 
pleasure. 

The  case  is  of  interest  in  its  medical  aspects  as  reproducing  some  of 
the  most  important  features  of  homicidal  impulse  in  the  insane.  There 
is  the  fact  of  the  peculiarly  hereditary  nature  of  impulsive  insanity; 
there  is  the  strange  association  of  deranged  organic  sensations  with 
the  convulsive  conduct ;  there  is  the  emphatic  proof  of  the  fatal  effects 
of  alcoholic  indulgence  in  such  cases,  and  the  ready  passage  into 
delusional  forms  of  insanity  ;  and,  lastly,  there  is  the  secrecy  so  often 
maintained  by  the  subjects  of  this  form  of  malady,  lasting  over  a  period 
of  ten  years.  A  notable  instance  is  recorded  by  Dr.  Tuke  *  of  a  young- 
man,  aged  twenty-five  years,  of  gentlemanly  appearance  : — 

"After  giving  his  address,  and  declaring  himself  to  be  a  schoolmaster  in  a  certain 
well-known  college,  he  begged  that  the  commissary  of  police  would  take  him  in 
charge,  with  a  view  to  his  confinement  in  the  asylum  of  St.  Ann.  He  then 
explained  that  he  was  not  mad  in  every  respect ;  on  the  contrary,  he  possessed  the 
full  use  of  his  mind,  only  whilst  sleeping  amongst  the  pupils  confided  to  his 
charge  he  was  seized  with  the  most  destructive  inclinations.  Night  after  night,  in 
an  agony  of  fear,  he  had  struggled  with  himself,  and  it  was  with  the  greatest 
difficulty  that,  so  far,  he  had  succeeded  in  restraining  his  intense  desire  to  strangle 
one  or  two  of  the  little  boys.  Now  all  his  energies  were  exhausted;  he  felt  that 
this  unknown  power  would  ultimately  triumph  over  him,  and,  rather  than  commit 
the  crime,  he  placed  himself  in  the  hands  of  the  police.  At  this  moment  a 
boy  accused  of  theft  was  brought  into  the  room.  The  eyes  of  the  schoolmaster 
were  immediately  lit  with  a  strange  light,  and,  had  it  not  been  for  the  timely 
assistance  of  a  brawny  policeman,  the  boy  would  have  been  throttled  before  the 
verj'  eyes  of  justice." 

We  have  little  doubt  that  many  instances  of  mysterious  suicides  are 
to  be  accounted  for  by  the  prevalence  of  homicidal  feelings — the  victim 
tortured  by  the  terrible  secret  seeks  relief  in  self  destruction  rather 
*  Psijchological  Medicine,  1S74,  p.  26S. 


ISl  THE   FULMIXATIXG    PSYCHOSES. 

than  reveal  his  condition,  or  subject  those  near  and  dear  to  him  to  any 
further  risk.  The  condition  of  the  homicidal  subject  immediately 
subsequent  to  the  act  is  characteristic — it  is  usuallv  one  of  complete 
relief  from  anxiety,  and  utter  indifference  to  the  enormity  of  his  crime; 
fi^quently  his  first  act  is  to  coolly  confess  his  crime  and  give  himself 
up  to  justice. 

Exceptions,  however,  occur  where  the  subject  of  insane  impulse 
endeavours  to  conceal  his  crime  like  the  responsible  criminal.  Thus, 
at  the  West  Riding  Asylum,  a  subject  of  such  impulses  secured  an 
iron  bar  and  struck  a  harmless  imbecile  patient  on  the  head  as  he  lay 
asleep  within  a  few  yards,  fracturing  his  skull  seriously,  and  then 
deliberately  concealed  the  instrument  in  some  shrubbery  near  at  hand, 
and  coolly  took  up  the  paper  he  had  been  reading  a  moment  before, 
apparently  free  from  the  least  concern.  Up  to  the  present  day,  four 
years  since  his  homicidal  act,  he  denies  positively  any  knowledge  of 
the  affair,  and  he  exhibited  the  utmost  indifference  on  being  questioned 
immediately  subsequent  to  his  violence.  In  fact,  his  nonchalance  at 
the  time,  and  his  subsequent  behaviour,  might  almost  have  been 
rec^arded  as  consistent  with  the  impulsive  automatic  act  of  an  epileptic, 
were  it  not  that  the  subsequent  history  of  the  case  revealed  clearly  the 
existence  of  insane  impulses  preceded  by  a  definite  aura,  but  not  of 
genuine  epileptic  paroxysms  :  and,  moreover,  proved  him  to  be  pos- 
sessed of  considerable  insane  cunning.  In  the  genuine  impulsive 
forms  of  insanity,  consciousness  is  never  so  fer  impaired  as  to  issue  in 
forgetfulness  of  the  details  of  the  homicidal  act.  "VThen  such  is  the 
case — when  any  marked  obscuration  of  memory  is  apparent — we  may 
presnme  the  impulse  to  have  been  of  epileptic  origin,  or  to  be  the 
outcome  of  alcoholic  delirium. 

Etiology. — In  all  these  cases  of  pure  impulsive  insanity  there  is,  we 
believe,  a  weU-established  basis  of  a  neurotic  heritage,  and  if  the 
individual's  history  is  scrutinised  with  sufficient  care,  we  are  assured 
that  evidence  of  niental  instability  will  be  discoverable  throughout  his 
life.  It  is,  however,  at  the  critical  epochs  of  life  that  this  predisposi- 
tion especially  tends  to  assert  itself — periods  at  which  grave  nutritional 
disturbances  are  prone  to  arise  in  the  central  nervous  system,  inducing 
the  peculiarly  convulsive  outflow  of  nervous  energy  which  characterises 
these  epochs,  even  in  normal  physiological  operations.  Puberty  and 
the  climacteric  are  prone  to  the  convulsive  type  of  the  neuroses,  and 
the  same  prevails  at  the  puerj^eral  period  during  lactation,  and  associ- 
ated with  the  various  forms  of  meTUtrual  derangenx^rd.  Several 
instances  are  on  record  where  the  revolutionary  epoch  of  puberty 
has  aroused  the  homicidal  feelings  in  youth,  as  in  the  case  of  Margaret 
Messenwer,  aged  thirteen  years,  who  killed  her  brother  and  drowned 


ETIOLOGY    OF    IMPULSIVE    IXSAXITY.  185- 

another  child,  six  months  old,  "without  any  discoverable  motive. 
Young  girls  suffering  from  temporary  menstrual  derangement  are 
subject,  as  is  well-known,  to  various  perverted  instincts  and  appetites^ 
and  the  hysterical  outbursts  are  often  associated  with  an  almost 
irresistible  tendency  to  destructiveness,  and  not  very  rarely  with  a 
homicidal  feeling  (see  case  of  Reg.  v.  Brixey).*  We  have  known, 
several  instances  where  the  subject  has  expressed  her  dread  of  sleep- 
ing in  the  same  room  with  other  members  of  the  family,  and  of  being 
left  alone  with  her  younger  sisters,  lest  she  should  not  be  able  to 
restr-ain  the  impulse  felt  to  injure  them. 

The  climacteric  in  woman  is  a  period  during  which  mental  dis- 
turbances are  frequently  associated  with  suicidal  impulse;  but,  as  we 
shall  see  later  on,  the  impulse  is  usually  the  outcome  of  intellectual 
derangement  and  grave  delusional  perversions.  Yet,  homicide  and 
suicide  may  occur  at  this  epoch  as  the  result  of  a  purely  impulsive 
condition,  and  more  particularly  in  such  cases  as  have  developed  intem- 
perate habits.  The  puerperal  period,  as  is  well-known,  renders 
neurotic  subjects  liable  to  insane  impulse,  and,  although  usually  a 
symptom  of  the  general  disturbance  of  puerperal  mania,  the  simple 
instinctive  form  may  alone  prevail.  We  recognise  a  similar  condition 
in  animals,  which,  in  the  deranged  states  following  parturition,  will 
kill  and  even  devour  their  young.  Epilepsy  is  a  frequent  source  of 
these  depraved  and  resistless  feelings.  Homicidal  impulses  may  prevail 
in  one  of  four  conditions  in  the  epileptic  subject,  viz.  : — 

(a.)  In  epileptic  furor  or  mania,  associated  with  hallucination  or 
delusion ; 

{h.)   In   the    so-called    '"'epilepsia    larvata"    (Jforel),    the    "masked 
epilepsy  "  of  Esquirol ; 

(c.)  In  the  dreamy  state  of  epilepsy ;  or,  lastly, 

(d.)  As  a  simple  impulsive  derangement  during  the  inter-paroxysmal 
period. 

It  is  the  latter  alone  which  can  be  regarded  as  genuine  Impulsive- 
Insanitv  :  the  three  former  conditions  are  attended  by  such  general 
mental  derangement  as  to  exclude  them  from  the  category  of  pure 
affective  forms  of  insanity.  It  will  be  more  convenient,  however,  to- 
refer  briefly  to  such  forms  at  the  present  juncture,  and  to  deal  with 
them  in  further  detail  in  our  remarks  upon  insanity  associated  with 
Epilepsy.  In  the  reductions  of  Epileptic  Mania,  or  the  post-par- 
oxysmal excitement,  of  which  we  see  so  much  in  our  asylums,  the 
homicidal  impulse  springs  into  life  almost  invariably  as  the  result  of 
delusion.  The  murderous  act  is  traced  to  a  pre-existing  delu- 
sioual  state,  with  which  it  has  often  a  direct  connection  (see  case  of 
*  Quoted  in  T.iylor"s  Medical  Jurisprudence,  vol.  ii.,  p.  564. 


IS6  THE   FULMINATING    PSYCHOSES. 

Reg.  V.  Taylor,  see  Alcoholic  Insaniti/) ;  or,  again,  hallucination  of  sight 
or  hearing  may  prompt  the  act — a  voice  may  be  heard  commanding  the 
epileptic  subject  to  kill,  and  the  impulse  arises  in  resistless  force  (case 
•of  £.  C,  see  Epileptic  I)isanity) — or  a  visual  hallucination,  in  the  form 
of  some  object  of  terror,  may  call  forth  these  same  results.  The 
epileptic  furor  may  be  of  some  considerable  duration,  and  the  subject 
remain  in  a  dangerously  homicidal  state  during  its  continuance ;  but 
subsequent  to  the  paroxysm,  the  subject  will  remain  either  greatly 
bewildered  (retaining  only  very  partially  some  fragmentary  recol- 
lections of  the  attack),  or,  still  more  commonly,  be  wholly  oblivious 
of  the  circumstances  and  of  the  conduct  which  he  has  just  displayed. 

In  the  masked  epilepsy  of  older  writers,  we  find  that  a  fit  of 
iomicidal  mania  may  replace  the  convulsive  seizure  (a  convulsive  idea, 
as  Maudsley  would  say,  takes  possession  of  the  mind),  and,  without 
any  of  the  usual  epileptic  phenomena  preceding,  a  sudden  irresistible 
murdei-ous  impulse  (probably  prompted  by  delusion  or  hallucination) 
occurs ;  but  here,  again,  the  subject  fails  to  recall  any  conception  of  his 
actions.  So,  likewise,  in  the  dreamy  state  of  epileptics,  approaching 
the  somnambulistic  condition,  homicidal  acts  have  been  committed  in 
a  semi-unconscious  automatic  state  of  mind.  It  is  astonishing  how 
complicated  may  be  the  acts  performed  in  these  states  by  the  epileptic 
automaton.  A  better  illustration  could  not  be  found  than  that  quoted 
by  Dr.  Gowers,  where  a  carman  in  this  state  of  automatism,  after  an 
epileptic  seizure,  "  drove  through  the  most  crowded  parts  of  London, 
uithout  any  object,  but  also  without  any  accident."  * 

Genuine  impulsive  insanity,  apart  from  grave  mental  derangement, 
however,  is  also  occasionally  seen  in  epileptic  insanity;  in  the  intervals 
between  the  convulsive  seizures,  certain  patients  are  subject  to  frequent 
insane  impulses  to  murder  f  without  any  motive  or  malice)  any  one 
'»vith  whom  they  are  brought  in  contact.  These  conditions  usually 
alternate  with  delusional  states,  and  with  the  maniacal  outbursts  suc- 
ceeding the  epileptic  attack — they  are  the  most  anxious  cases  to  treat, 
and  the  most  difficult  patients  to  control  Such  subjects  are  peculiarly 
susceptible  to  the  efi"ects  of  small  quantities  of  alcohol,  which  may 
induce,  even  in  very  trivial  amount,  the  most  furious  outbreak  of 
mania,  or  the  impulsive  homicidal  state  alluded  to. 

Alcoholic  excess  may  induce  the  impulsive  form  of  insanity  in 
certain  predisposed  neurotic  individuals ;  a  condition  of  alcoholic 
delirium  of  extremely  short  duration  (mania  transitoria)  f,  in  which  a 
mad   impulse   to  murder  prevails,   may  thus  be   induced  by  what  is 

*  Diseases  of  tlie  Xervous  System,  vol.  ii.,  p.  G91. 

-tMaadsley  is  undoubtedly  correct  in  asserting  that  many  cases  of  mania 
transitoria  are  really  instances  of  "mental  epilepsy." — Op.  cit.,  p.  230. 


THE    SUICIDAL    IMPULSE.  187 

■usuaHy  considered  by  no  means  immoderate  drinking.  The  symptoms, 
however,  embrace  much  mental  confusion,  and  the  suljject  remains, 
after  the  attack  is  over,  in  a  state  very  similar  to  an  epileptic  after  an 
attack  of  petit  mal.*  Amongst  other  ^etiological  factors  we  must  not 
fail  to  note  the  vicious  agency  of  imitation  which  was  originally 
emphasised  by  Esquii'ol,  as  one  of  the  causes  of  this  affection. 
Undoubtedly,  the  morbid  excitement  engendered  by  the  perusal  of 
records  of  criminal  horrors,  by  the  publicity  afforded  in  our  Assize 
Courts  to  the  revolting  details  of  crime,  and,  up  to  within  the  last 
few  years,  the  demoralising  effect  of  public  executions,  have  greatly 
fostered  the  development  of  these  states  of  mental  disease.  If  there 
is  one  fact  in  mental  physiology  more  established  than  others,  it  is 
that  the  continuous  direction  of  the  mind  to  the  sensual  and  purely 
animal  passions  of  our  nature  tends  to  intensify  their  potency — to 
render  their  channels  of  operation  more  pervious,  and  so  to  withdraw 
them  from  the  inhibitory  control  to  which  they  should  ever  be  subject. 
The  brutal  instincts  are  still  less  protected  in  those  persons  of  weak 
mind,  who,  not  endowed  with  an  average  amount  of  controlling  power, 
require  but  the  intensification  of  such  instinctive  states  to  lead  to 
explosive  outbursts ;  in  such  cases  mental  strain,  anxiety,  ill-health, 
and  other  exhausting  conditions,  and  especially  alcoholic  and  sexual 
intemperance,  may  readily  lead  to  attacks  of  homicidal  mania  at 
periods  when  the  public  mind  is  horrified  by  some  stai'tling  crime. 

The  Suicidal  Impulse.  —  What  ^-e  have  said  respecting  the 
homicidal  impulse  applies  in  most  particulai's  to  the  self-destructive 
propensity;  it  also  arises  in  subjects  who  exhibit  no  intellectual 
disturbance,  and  in  whom  the  moral  sense  is  intact,  in  so  fai',  that 
they,  recognising  the  horx-or  of  their  situation,  and  the  unnatural 
chax'acter  of  the  morbid  promptings,  revolt  against  the  perpetration 

*  On  the  subject  of  mania  transitoria  Maixdsley  remarks  : — "Although  epilepsy, 
masked  or  overt,  will,  I  think,  be  found  to  be  at  the  bottom  of  most  cases  of  mania 
transitoria,  it  must  be  admitted  that  there  ai'e  some  cases  in  which  there  is  no 
evidence  of  epilepsy  in  any  of  its  forms  to  be  found  ;  but  it  may  well  be  doubted 
Avhether  a  distinct  insane  neurosis  is  not  iilways  present  in  these  cases.  With 
sucli  a  constitutional  predisposition,  a  genuine  attack  of  acute  insanit}',  lasting  for 
a  few  hours  only,  or  for  a  few  days,  may  break  out  on  the  occasion  of  a  suitable 
exciting  cause,  and  during  the  paroxysm  homicidal  or  other  violence  may  be 
j)erpetrated.  After  childbirth  it  sometimes  happens  that  a  woman  is  seized  with 
a  paroxysm  of  acute  mania  of  short  duration,  during  which  perhaps  she  kills  her 
child  without  knowing  what  she  is  doing.  The  efiect  of  alcoholic  intemperance 
upon  a  person  strongly  predisposed  to  insanity,  or  upon  one  whom  a  former  attack 
has  left  predisposed  to  a  second,  is  sometimes  a  short  but  acute  mania  of  violent 
character  with  vivid  hallucinations  and  destructive  tendencies  ;  and  a  like  efl'ect 
may  be  produced  by  powerful  moral  causes,  sexual  excitement,  and  other 
recognised  causes  of  insanity."     (Refpojisibtlilij  hi  Mental  Disease,  p.  247.) 


188  STATES    OF    MKNTAI,    i:\FEEBLEMENT. 

of  the  act.  Like  tlic  homicide,  tliey  may  implore  protection,  and 
voluntarily  resign  themselves  to  asylum  supervision,  dreading  lest 
they  may  be  overmastered  hy  the  suicidal  impulse.  So  likewise  do 
we  find  the  impulse  of  convulsive  nature  sudden  in  its  onset,  transient 
in  its  course,  and  followed  by  immediate  and  complete  relief;  its 
analogy  to  the  epileptic  state  being  still  further  indicated  by  the 
occurrence  of  an  aura,  usually  an  aural  hallucination.  The  condition 
to  which  we  allude  is,  of  course,  not  the  ordinarj"-  suicidal  tendency  of 
simple  melancholia,  where  the  morbid  depression  pi'ecedes  and  ex- 
])lains  the  negative  suicidal  state ;  but  the  condition  Avhei'e,  from  the 
first,  the  suicidal  propensity  presents  itself,  any  depression  being 
secondary,  and  induced  by  the  patient's  helpless  condition.  The 
climacteric  epoch  not  imfrequently  develops  this  impulsive  form  of 
insanit}^  just  as  it  does  homicidal  states  ;  and  a  good  illustrative  case 
is  detailed  further  on  iu  our  study  of  the  insanity  prevailing  at  this 
period  of  life  (see  case  of  S.  II.)  Winslow  recoi-ds  the  statement 
of  one  patient  as  follows  : — ■"  For  six  months  I  have  never  had  the 
idea  of  suicide,  night  or  day,  out  of  my  mind.  Wherever  I  go,  an 
unseen  demon  pursues  me,  impelling  me  to  self-destruction.  My  wife, 
friends,  and  children  observe  my  listlessness  and  jierceive  my  des})on- 
dency,  but  they  know  nothing  of  the  Avorm  that  is  gnawing  within."  * 

STATES  OF  MENTAL  ENFEEBLEMENT. 

Contents. — Mental  Deprivation  in  Contradistinction  to  Developmental  Arrest — 
Persistent  Enfeeljlement— Chronic  Eesidiie  of  Asylnni  Coinmnuities — Recover- 
ability  of  Maniacal  and  j\lelancholic  Forms— Consecutive  Dementia— Delusional 
Insanity— Genesis  of  Monomaniacal  States — Environmental  Eesistance— Trans- 
formation Completed— Mystic  Symbolism— Illustrative  Cases  of  Delusional 
Insanitj'— Monomania  of  Pride  (.1.0.,  E.T.) — Religious  Monomania  (J.B.) — 
Monomania  of  Persecution  (E.C). 

Amongst  states  of  mental  enfeeblement  are  comprised  numerous 
■widely  different  groups,  which  constitute  the  large  bulk  of  our 
asylum  communities,  and  in  which  the  mental  ailment  difi'ers  in  its 
mode  of  origin,  essential  nature,  and  the  characteristic  features 
presented.  The  term  mental  "  enfeeblement "  is  jierhaps  the  least 
objectionable  which  we  may  employ  for  the  varioi;s  groups  comprised 
under  this  class  of  mental  ailments,  but  there  is  a  sense  in  which 
its  application  is  faulty.      The  term  should,  we  think,  include  states 

of  mental   deprivation  only— fe.,  states  of  acquired   defect, 

whilst  comjeuital  and  developmental  arrest  would  be  more  appropri- 
ately considered  under  a  distinct  categor}'.  Idiocy  and  imbecility  would, 
therefore,  be  excluded  from  this  class,  which  would,  however,  compi'ise 
the  various  forms  of  monomania,  of  chronic  mania,  and  dementia. 

*  Obscure  Diseases  of  the  Brain,  p.  265. 


TRANSIENT    AND    PERSISTENT    ENFEEBLEMENT. 


189 


All  instances  of  mental  reduction  are,  of  course,  states  of  mental 
enfeeblement,  and,  therefore,  in  one  sense,  all  cases  of  acute  insanity 
are  alike  cases  of  mental  enfeeblement,  as  is  the  stage  of  stupor  fol- 
lowing acute  insanity,  or  an  epileptic  outburst.  We  do  not,  however, 
extend  to  this  term  so  wide  a  significance ;  we  arbitrarily  exclude 
states  of  transient  mental  deprivation,  and  limit  its  connotation  to 
conditions  of  persistent  enfeeblement,  whetlier  primary  or  con- 
secutive in  their  origin.  In  fact,  we  comprise  under  it  the  incurable 
terminations  of  acute  insanity— the  chronic  insane  residue  which 
remains,  as  wrecks  remain  after  the  storm  ;  also,  such  cases  of  per- 
manent enfeeblement,  as  are  not  preceded  by  acute  mental  symptoms, 
e.g.,  the  "primary  dementia"  of  organic  disease  of  the  brain — from 
morbid  growth,  apoplectic  foci,  and  cerebral  ramollissement — and  the 


Number 

of 
Cases. 

Percentage. 

Form  of  Mental  Disease. 

Recovered. 

Died. 

Relieved. 

Chronic 
Remainder. 

Per  cent. 

Per  cent. 

Per  cent. 

Per  cent. 

134 

Mania — Simple,  .... 

61 

11-9 

11 

16 

201 

Acute,    . 

65-5 

13-4 

8-4 

11-9 

66 

Hysteric, 

75-7 

3-0 

9  0 

12  0 

46 

Chronic, 

13 

36-9 

50-0 

237 

Delusional, 

37-0 

130 

lS-5 

31-0 

85 

Recurrent, 

57-6 

8-2 

14-0 

20  0 

46 

Puerperal, 

71-7 

15-2 

6-5 

6-5 

141 

Melancholia — Simple, 

61-7 

14-0 

13-4 

10-6 

51 

Acute, 

54-9 

23-5 

5-S 

15-6 

299 

Delusional,    . 

55'5 

14-0 

14-3 

160 

16 

Recurrent,     . 

50  0 

12-5 

12-0 

25-0 

11 

With  Stupor, 

63-6 

9-0 

27-2 

68 

Dementia — Senile, 

60-0 

26-4 

13.-0 

28 

With  Excitement,     . 

39-0 

35-7 

10-7 

14-2 

39 

,,      Depression, 

41-0 

23  0 

28-0 

7-6 

33 

Organic,    . 

9-0 

54-0 

30-0 

6  0 

121 

Epilepsy, 

11 -o 

20-4 

23  0 

38-8 

74 

General  Paralysis, 

72-9 

21-6 

5-4 

82 

Imbecility,  ..... 

17  0 

51-3 

30-7 

13 

Idiocy, 

38  4 

15-3 

45-9 

IS 

Chronic  Cerebral  Atrophy, . 

77"7 

22  0 

1809 

190  STATES    OF    MKNTAL    KNFKKDLKMENT. 

dementia  of  senile  atrophy.  Under  tlie  respective  headings  of  epileptic, 
apoplectic  or  paralytic,  senile,  and  alcoholic  insanities,  we  shall  allude 
to  the  features  presented  by  the  mental  decadence  accompanying  such 
affections;  but  we  must  here  devote  our  attention  to  a  consideration 
of  consecutive  dementia  as  a  sequel  to  the  acute  forms  of  mental 
disease  in  general. 

A  glance  at  the  preceding  Table,  which  affords  us  the  results 
of  treatment  in  the  case  of  1,809  female  patients  admitted  into  the 
"West  Riding  Asylum,  Avill  serve  to  indicate  whence  our  chronic  insane 
inmates  are  chiefly  dei'ived. 

In  the  Table  it  will  be  observed  that  a  large  proportion  of 
maniacal  and  melancholic  patients  are  discharged  "relieved,"  and  this 
class  comprises  a  number  of  iKrmanenthj  enfeebled  minds,  in  which  the 
acute  symptoms  having  subsided,  the  subjects  are  safely  disposed  of 
under  the  care  and  supervision  of  their  friends ;  hence  the  chronic 
remainder  in  our  asylums  do  not  represent  by  a  long  way  the  COn- 
secutive  dementia  of  acute  insanity.  Bearing  this  fact  in  mind,  one 
may  still  advantageously  compare  the  total  number  of  chronic  cases 
remaining  after  maniacal  and  melancholic  seizures  respectively — it  is 
then  found  that  out  of  815  instances  of  all  the  forms  of  mania,  a 
percentage  of  20"6  remain  permanently  crippled  in  mind;  and  that  out 
of  a  total  of  518  instances  of  melancholia,  a  percentage  of  15'0  remain 
as  a  chronic  residue. 

This  is  what  we  might  anticipate  from  our  knowledge  of  the  deeper 
reductions  pertaining  to  the  maniacal  forms,  and  confirmatory  of  it  we 
note  a  progressively-increased  tendency  to  chronic  enfeeblemcnt,  result- 
ing in  the  acute,  delusional,  and  recurrent  forms,  as  compared  with  the 
simple  form  of  melancholia  {vide  Table).  If  we  summarise  results  for 
all  forms  of  mania  and  melancholia,  we  obtain  the  following : — 


Percentage 

Chronic 

Recovered. 

Died. 

"Relieved."' 

Remainder. 

Maniacal  forms. 

.        53-2 

11-9 

14-0 

20-6 

Melancholic   „ 

.       57-i 

U-8 

12-9 

15-0 

The  more  unfavourable  chai-acter  of  mania  depends  upon  the  incur- 
ability of  its  delusional  forms  ;  the  simple  and  acute  maniacal  seizures, 
if  they  do  not  tend  to  the  delusional  form,  are  usually  of  high  recover- 
ability,  as  indicated  by  our  table ;  certain  forms  especially  so,  as  the 
puerperal  and  hysterical.  Were  it  not  for  the  large  proportion  of 
suclb  acute  cases,  the  unfavourable  nature  of  maniacal,  as  compared 
■with  the  melancholic  forms  of  insanity,  would  be  strikingly  obvious. 

Consecutive  Dementia. — Ordinary  consecutive  dementia,  how- 
ever, presents  us  with  a  progressively  advancing  enfeeblemcnt  of  mind, 


COXSECUTIVE    DEMENTIA.  191 

a  complete  change  in  tlie  disposition  and  character  of  the  patient,  a 
lack  of  interest  in  former  pursuits  and  associations,  an  incapacity  for 
any  form  of  mental  effort,  a  tendency  to  an  automatic  routine  in  the- 
habits  of  life,  and  a  notable  blunting  of  the  emotions.  Maniacal  or 
melancholic  states  occasionally  return,  and  betray,  in  a  marked  degree, 
the  incoherence  of  thought  and  the  enfeeblement  of  the  mental  faculties ; 
but,  subsequent  to  such  attacks,  the  mental  weakness  continues  to 
advance,  until  it  issues  in  complete  fatuity.  Yet  we  find  great  diver- 
sity in  the  progress  of  individual  cases  :  in  many,  the  advent  of  such  a 
mental  void,  as  we  have  just  alluded  to,  only  comes  after  a  very  pro- 
longed life,  during  which  they  show  no  mental  perturbations,  but  an 
apathy  and  indifferentism,  a  lack  of  initiative  which  renders  super- 
vision necessary  to  provide  them  with  the  wants  of  life ;  others  take 
a  more  genial  interest  in  their  surroundings,  but  yet  are  childish  in' 
their  actions,  are  docile  and  easily  led,  but  subject  to  great  instability 
if  annoyed ;  in  others,  again,  the  brutalising  of  their  nature  is  more' 
apparent — degraded  habits  come  to  the  front,  vicious  tendencies  are 
apparent,  but  conduct  is  wholly  devoid  of  all  intelligent  direction  or 
rational  initiative.  Many  of  these  chronic  dements  are  utterly  lazy, 
disinclined  for  any  form  of  exertion,  and  cannot  be  induced  to  employ 
themselves  at  the  simplest  manual  labour.  They  will  stand  about  foi' 
hours,  slovenly  and  disorderly  in  attire,  fumbling  with  their  fingers,, 
disarranging  or  tearing  their  clothing,  and  uttering  continuously  a 
string  of  incoherent  gibberish.  Some  of  these  subjects  may  have  no- 
delusion  apparent,  as  a  rule;  but  yet,  at  times,  a  mild  maniacal  attack 
may  reveal  some  delirious  conception,  which  again  fades  away  as  the 
excitement  abates.  The  expressionless  features  betray  the  lifelessness. 
of  mind ;  or  a  fixed,  hideous  grimace,  or  unmeaning  aspects,  its- 
unreason. 

It  would  not  serve  our  purpose  here  to  attempt  any  classification 
of  such  numerous  and  incongruous  types  as  ai'e  presented  by  the 
cases  of  chronic  enfeeblement  amongst  the  insane ;  they  can  only  be 
studied  by  prolonged  clinical  observation  in  the  wards  of  an  asylum.. 
Griesinger  has,  however,  distinguished  between  the  class  of  excitable- 
and  that  of  apathetic  dements,  and  to  his  vivid  delineation  of  these- 
types  we  would  direct  the  student's  attention.*  They  represent  but 
different  depths  of  reduction,  the  former  being  allied  to  mania — 
in  fact,  retaining  a  certain  degree  of  its  mobility  as  relics  of  the 
maniacal  condition ;  the  latter  being  the  more  profound  reduction,  in 
which  sluggishness  of  mind  verges  upon  absolute  fatuity.  We  shall 
revert  to  the  morbid  evolution  of  these  phases  of  dementia  in  our 
section  on  the  morbid  histology  of  the  brain. 

*  Op.  cit.,  pp.  340-315. 


192  STATICS    OF    MENTAL    EN'FEEBLEMENT. 

The  transition  from  acute  insanity  is  by  no  means  always  a  direct 
transition  to  these  forms  of  mental  enfeeblement — an  intermediate 
stage  of  peculiar  chronicity  often  precedes  the  more  profound  dementia 
which  we  have  just  considered.  To  these  forms  of  monomania  or 
delusional  insanity  proper,  we  must  now  revert. 

Delusional  Insanity. — We  have  spoken  of  maniacal  states  as 
jjresrntiiig  us  with  reductions  to  a  stage  lower  than  that  attained  by 
melancholic  states ;  and  we  now  come  to  a  group  of  cases  comprising 
symptoms  wholly  distinct  from  those  presented  to  us  by  the  foregoing. 
"This  third  group  lies,  so  to  speak,  in  the  order  of  dissolutions,  on  the 
border-land  between  the  two  former.  In  the  first  (mania),  we  noted 
the  general  exaltation  and  the  free  translation  into  action ;  in  the 
second  (melancholia),  we  observed  the  rise  of  painful  feeling  associated 
with  general  depression  and  restricted  activity  ;  in  the  third  we  find,  as 
■often  as  not,  an  emotional  indifierentism  allied  with  false  beliefs  of  an 
exalted  stamp — a  calm,  which  is,  however,  ever  ready  to  pass  into 
states  of  transient  excitement,  on  the  one  hand,  or  into  gloom  and 
'despondency  on  the  other.  This  third  group  comprises  the  so-called 
states  of  monomania.  ^Monomania  as  a  morbid  entity  must  be  re- 
garded as  a  state  evolved  out  of  melancholic  and  maniacal  perversions — 
as  a  special  derivative  of  these  conditions ;  never  as  a  primary  form  of 

disease,  but  as  itself  one  of  the  terminations  in  chronic  insanity. 

It  can  be  studied  to  the  gx'eatest  advantage  in  association  with  the  pre- 
ceding forms ;  nor  is  it  possible  correctly  to  appreciate  its  significance, 
if  we  have  not  previously  analysed  the  forms  of  melancholic  and 
maniacal  perversions. 

Genesis  of  Monomaniacal  States.— We  have  seen  that  a  special 
feature  of  maniacal  states  is  the  hurry  and  tumult  of  the  process,  and 
the  prevalence  of  delusive  conceptions  of  a  fleeting  nature.  It  is  this 
very  I'apidity  of  the  cerebral  process  which  accounts  for  the  transient 
nature  of  such  falsifications ;  time  is  required,  a  certain  persistence  of 
impression,  or  a  frequent  repetition  of  the  same  impression,  to  form 
any  indelible  stamp  upon  the  memory.  As  stated,  one  delusion 
c-hases  another  out  of  the  mind  in  the  tumultuous  superficial  hurry  of 
the  maniacal  state.  The  welling-up  of  feeling,  which  we  have  spoken 
of  as  the  rise  in  subject-consciousness,  finds  easy  vent  in  mania  in 
rapid  ideation,  incessant  garrulity,  and  active  movement ;  yet  all 
maniacs  obtain  at  times  full  relief  in  active  ideation  alone — for  the 
maniacal  subject  need  not  be  at  all  times  restless,  nor  need  he  be 
garrulous — yet  his  expression  will  indicate  to  us  the  varying  moods 
and  rapid  process  of  incoherent  thought  goijig  on  within.  We  speak 
occasionally,  but  incorrectly,  of  such  cases  as  instances  of  siippressed 
mania — there  is  no  mental  tension,  but  complete  relief  in  the  active 


MONOMANIACAL    PERVERSIONS.  193 

ideational  process.  Monomauiacal  states  are  essentially  those  where 
the  rise  in  sul)ject-consciousness  does  not  tend  to  r.^cape  in  outward 
action,  but  rather  to  find  relief  in  forms  of  perverted  ideation  ;  and 
hei'ein  lies  the  distinction  between  the  two  forms — in  monomania  there 
is  no  longer  emotional  exaltation  and  tumult,  but  perfect  calm ;  the 
false  conceptions  arising  at  these  levels  of  reduction  have  a  far  more 
serious  import,  since  the  existing  conditions  favour  their  fixity.  They 
rise  more  definitely  and  more  for'cibly  into  consciousness. 

The  turbulence  of  the  intellectual  life  in  mania  and  the  heightened 
mental  reflex,  we  have  associated  with  spasm  of  the  cerebral  arterioles, 
and  the  resultant  quickened  circulation  in  the  cerebral  cortex ;  in 
monomaniacal  states,  a  quiescence  of  the  circulatory  current  appears 
coeval  with  the  decline  of  such  exalted  cerebral  reflex,  and  we  approach 
the  stage  of  melancholic  reductions  except  for  the  absence  of  vaso- 
motor paresis  and  the  stagnant  circulation  of  the  latter  states  ;  hence,  in 
lieu  of  a  feeling  of  restricted  translation  from  emotional  to  intellectual 
realms,  the  feeling  of  freedom  and  power  still  predominates.  Such 
freedom,  as  before  stated,  finds  its  output  in  phases  of  aberrant 
ideation. 

And  yet  there  are  times  when  the  monomaniac  realises  somewhat 
painfully  a  sense  of  environmental  resistance — a  sense  which  must  be 
generated  whenever  he  attempts  to  put  his  impossible  schemes  into 
practical  operation,  or  tries  to  convince  others  of  the  logicity  of  his 
absurd  speculations  and  belief.  Especially,  however,  does  this  sense 
of  resistance  make  its  appearance  in  cases  of  fully  developed  mono- 
mania, where  languor  of  circulation,  induced  by  cardiac  enfeeblement 
and  exhausting  aff'ections,  such  as  phthisis,  reproduces  the  melancholic 
phase  afresh.  This  sense  of  outward  hostility — the  irritation  and 
excitement  thereby  engendered — is  a  more  prominent  feature  in  the 
earlier  stage  of  monomania ;  and  in  most  cases  it  is  found,  in  some  one 
or  other  form,  at  this  period  of  the  disease,  as  the  natural  outcome  of 
the  antagonism  which  the  subject  must  recognise  as  existing  between 
his  beliefs  and  "the  circumstances  around  him.  It  is  a  feature  which 
indicates  the  incomplete  severance  of  this  afiection  from  the  purely 
maniacal  form.  As  the  mania  subsides  and  calm  succeeds — as  the 
egoistic  feelings  predominate  more  and  more,  and  obtain  more  complete 
ascendancy  over  the  intellectual  life,  the  transformation  slowly,  but 
elaborately,  undergone  by  the  personality  is  in  itself  a  sufficient  answer 
to  all  outward  antagonism ;  the  all-sufliciency  of  the  ne-w  ego,  with  its 
wondrous  powers,  capabilities,  and  motives  for  action,  dissipates  all 
apparent  opposition,  or  ignores  its  existence. 

It  is  thus  that  we  find  our  patients  at  first,  in  the  early  transition- 
period  between  mania  and  monomania,  intolerant  of  contradiction — no 

13 


194  STATES    OF    MENTAL    ENFEEBLEMENT. 

opposition  offered  to  their  delusive  utterances  fails  to  arouse  passionate 
outbursts,  violent  abuse,  and  even  vindictive  conduct ;  he  who  risks 
this  often  wins  for  himself  the  open  and  long-continued  hostility  of 
the  patient,  at  no  time  a  justifiable  or  politic  procedure.  At  this  stage, 
the  deluded  subject  is  loudly  assertive  of  his  beliefs,  and  actively 
aggressive  in  his  endeavours  to  carry  them  into  practical  operation  ; 
in  interminable  writings,  in  incessant  declaration  he  will  assert  his 
newly-acquired  prerogatives ;  whilst  acute  hallucinations  frequently 
occur  at  this  period,  lending  fresh  intensity  to  the  drama  which  he 
enacts. 

In  the  more  confirmed  calm  of  a  later  stage,  a  love  of  mystiC 
Symbolisin  is  almost  invariably  apparent ;  the  monomaniac  will 
point  to  some  common-place  picture  on  the  wall,  expatiating  on  its 
secret  meaning ;  he  will  assume  some  fantastic  badge  as  the  emblem  of 
his  exalted  dignity — spiritual  or  temporal ;  by  fantastic  gestures  or 
significant  movements  of  the  head  he  will  express  some  meaning 
hidden  from  all  except  himself;  or  by  uncouth  scrawls,  or  geometric 
devices,  he  will  symbolise  Scriptural  truths,  Biblical  records,  or 
scientific  discoveries.  By  such  means  endlessly  diversified,  the  sub- 
jects of  monomania  beguile  their  time,  and  form  meanwhile  prominent 
characters  in  all  asylum  communities.  Their  loud  threats,  their  lofty 
denunciations,  their  fulminating  proclamations,  contrast  strangely 
with  their  impotence  in  action.  They  live  in  an  ideal,  not  a  real, 
world ;  and  are  satiated  to  the  full  by  the  mere  semblance  of  authority 
and  power  which  such  expressions  conjure  up.  On  this  account  they 
are  rarely  violent  and  never  dangerous  patients ;  they  are  ruled  with 
the  greatest  facility,  requiring  only  tact  upon  the  part  of  the  nurse  to 
transform  them  into  most  useful  and  willing  helping-hands  at  various 
employments.  Thus  we  see  the  patriarch  and  delegate  of  the  Deity 
[J.  0.)  actively  at  work  in  the  bookbinder's  shop  of  the  West  Riding 
Asylum ;  the  Empress  of  Hermon  {E.  P.)  busily  plying  the  needle, 
trimming  the  patients'  bonnets  in  the  workroom ;  the  "  Saviour  of 
mankind  "  (.7.  B)  taking  an  active  part  in  the  domestic  arrangements 
of  her  ward ;  and  a  notorious  admiral  who  formerly  ruled  the  seas  in 
days  gone  by,  contentedly  framing  pictures  in  the  joiner's  shop. 

Cases  of  Monomanixi. 

In  the  following  case  of  J.  0.  we  see  the  subject  pass  through  the 
transition  period  from  mania  to  genuine  monomania ;  his  case  forms  a 
good  illustration  of  the  mystic  symbolism  in  which  these  patients,  as 
we  have  said  above,  so  frequently  indulge : — 

J.  0.,  formerly  a  prison  warder  in  South  Wales,  has  been  resident  at  the  West 
Riding  Asylum  for  nearly  nine  years.     When  first  admitted  he  was  thirty-six 


CASES    OP    MONOMANIA.  195 

yeai'S  of  age,  a  well-nourished  man  of  medium  height,  and  free  from  any  Ijodily 
ailments.  His  wife  had  long  recognised  his  mental  failure,  but  maniacal  excitement 
had  now  compelled  her  to  place  him  under  restraint.  He  was  at  this  time, 
undoubtedly,  the  subject  of  fixed  delusions:  "all  human  agencies  were  in  league 
against  him,  and  there  was  a  conspiracy  in  high  quarters  to  damage  him."  He  had 
written  to  the  prison  commissioners  repeatedly  about  these  plots,  and  was  at  that 
time  writing  a  book,  on  "Religion."  He  talked  much  about  various  instruments  he 
had  invented,  especially  "an  air  and  water  engine,  requiring  no  boiler,"  for  which 
he  was  about  to  obtain  a  patent.  His  condition  at  this  time,  and  during  the  following 
twelve  months,  was  much  mixed-up  with  mauiacal  excitement — in  fact,  it  was  the 
transition  period  to  typical  monomania.  During  this  period  he  was  often  hostile, 
most  unsociable,  and  utterly  indolent ;  had  an  arrogant,  overbearing  demeanour ; 
stalked  up  and  down  the  wards  as  though  in  a  position  of  authority,  and  grew 
angry  at  the  most  trifling  opposition.  He  was  usually  reticent,  but  occasionally 
talked  upon  the  subject  of  his  inventions  and  of  his  experiments  upon  lightning, 
which  he  had  conducted  by  "  holding  pieces  of  various  metals  in  his  hand  during  a 
thunderstorm."  He  then  commenced  working  on  the  farm,  but  would  spend 
most  of  his  spare  time  reading  his  Bible — making  many  differently  shaped  crosses 
out  of  bits  of  wood,  straw,  &c.,  often  carrying  one  in  his  hand.  He  declares  that 
he  was  wrongfully  sent  here ;  that  he  is  deputy-governor  of  a  gaol,  and  possesses 
the  warrant  of  his  appointment;  and  that  he  has  made  numerous  discoveries  in 
electricity  and  magnetism.  Since  this  period  he  has  been  regularly  employed  in 
the  bookbinder's  shop,  where  he  is  a  useful  and  industrious  worker;  he  is  an 
intelligent  workman,  and  is  calm  and  consistent  in  his  behaviour  at  all  times, 
outwardly  betraying  no  evidence  of  the  profoundly  delusive  state  under  which  he 
labours.  He  regards  himself  as  a  patriarch  of  the  church,  and  as  the  appointed  of 
God  to  denounce  judgments  against  all  evil-doers.  Feeling  his  confinement  here 
inconsistent  with  these  views,  he  applies  to  all  the  crowned  heads  of  Europe  for 
assistance  against  the  perseci;tions  of  the  medical  profession,  of  whom  the  writer  is 
the  arch-traitor.  He  writes  denunciatory  letters  to  the  medical  superintendent, 
calling  upon  his  head  the  curse  of  the  Almighty,  and  sends  him,  every  week  or  so, 
a  pen  and  ink  outline  sketch  of  a  coffin,  as  a  last  warning,  often  accompanied  by 
the  words,  "Behold  thy  doom;"  addressing  his  missives,  "To  all  whom  it  may 
concern,"  or  "Let  this  find  its  owner,"  with  some  similar  suggestive  memento  mbrl. 
Occasionally  his  letters  to  the  medical  staff  are  lengthy  and  argumentative,  freely 
interspersed  with  numerous  texts,  or  scriptural  references,  containing  also  words  of 
exhortation  and  warning,  often  dictated  in  the  style  of  the  New  Testament  writings ; 
but  it  is  more  usual  to  find  them  full  of  fierce  denunciation  and  threats  of  divine 
judgment,  as  e.g.,  the  following: — 

"  May  6,  1SS7. 
"  Professed  Englishmen  or  Britons, 

"I,  an  English-born  subject,  J.  0.,  born  in  the  County  of 
Yorkshire,  near  Huddersfield,  Do  hereby  solemnly  declare  in  the  name  of  'God,' 
the  Almighty,  the  Supreme  and  Invisible  Spirit,  and  pronounce  through  His 
Almighty  authority,  His  damnable  curses  and  judgments  upon  you,  and  your 
supposed  and  so-called  Gracious  Sovereign  and  all  her  subjects,  both  spiritual 
and  temporal,  for  this  my  incarceration  in  this  Asylum  or  any  other. 

"J.  0.,  late  of  Hahfax." 


196  STATES    OF    MENTAL    ENFEEDLEMENT. 

A  few  mouths  later  the  following  incoherent  address  was  issued  : — 

St.  John  vi.,  31,  49,  50,  51.  Hebrews  ix.,  4.  1  Corinthians 
ix.,  11-27;  xii.,  12-36.  2  Corinthians  viii.,  12-15,  20,  21; 
i.x.,  6-9,  10,  11  ;  xi.,  22,     Galations  iii.,  2,  4,  5,  10,  20,  21, 

22,  23,  24,  25,  26,  27,  28,  29  ;  v.,  IG,  17,  IS,  19,  20,  21,  22, 

23,  24;  vi.,  8-16. 

Ckntlemen, — Now  you  may  be  able  to  judge  for  yourselfs  once  more;  whom  is 
most  ablest,  to  the  work  of  a  Doctor  or  Physician  of  Bodily  weakness,  temporally, 
moral  or  as  Physician  of  the  Soul;  spiritually  according  to  the  Gift  of  the  Grace 
of  "God,"  and  of  His  Spirit;  for  His  Spirit  lies  in  a  vast  number  and  quantity  of 
human  and  animal  beings,  in  different  ways  and  forms,  actively  and  inactively ;  I 
should  think  it  is  quite  essentially  that  you  may  perhaps  have  known  these  things, 
but  how  arbitrary  and  selfish  have  you  seemed  to  hold  them  so  close ;  which  may 
well  be  defined  in  one  single  instance  through  your  Incapacity  in  not  being  able  to 
discharge  me,  your  supposed  patient  in  Lunac}',  whose  name  is  and  ever  was  J.  0. 
in  England,  his  Home-born  countrj\ 

Believe  me,  yours  ever 

Faithful  and  sincere, 

Dr.  J.  0., 

PItysician  Temporal  and  Spiritual  of  Ikulti, 
Y,Jl,  Mind,  and  Soul. 

To  Professio  Medico  De  la  Russ; 
Austria;  Germany  et  Prussia; 
Italia  et  Continental  Europe. 

He  then  proceeds  to  call  down  the  anathemas  of  the  Romish  Church  upon  his 
persecutors,  addressing  long  epistles  to  "the  Head  Pontiff  of  the  Church  of 
Rome,"  every  other  word  or  so  in  his  address  distinguished  by  a  capital  letter. 
Another  of  his  curious  vagaries  showed  itself  prominentlj'^  at  this  time,  and  he 
essayed  to  address  the  various  European  potentates  all  in  their  own  tongue, 
or  rather  in  a  garbled  mass  of  foreign  and  unmeaning  words,  strung  together  in 
the  form  of  an  epistle — affecting  Latin,  Greek,  German,  French,  Spanish,  Italian. 
These  productions  of  his  facile  pen  were  often  decorated  by  a  cross,  a  crown,  an 
archbishop's  mitre,  a  national  flag  or  other  device  in  coloured  inks.  The  following 
is  a  fragment  of  one  of  his  strange  letters  to  the  Spanish  Consul  in  South  Wales: — 

"Marzo,  Tkiext.\, 

"DlEZ  Y  OCHO  OCHENTA   SlETA. 

"MoN  Amlso, — Escribo  si  bien  me  acuerdo  caballero  ;  hace  mas  de  cinto  amos 
entonces  envoyo  aquis  ;  yo  lo  pongo  en  usted  a  Judicio  la  mameso ;  yo  no  u 
minimo  el  loco ;  telmpo  acero  envoyo,  ni  el  altro  entonces,  Siempre  Bastante 
bien  a,  ir  grande.     Que  le  parece  u  usted,  &c.,  &c. 

"JOSE  0. 
"espanal  consulato, 

"Cardiff,  Wales." 

But  our  friend,  J.  O.,  was  shrewd  enough  to  turn  such  vagaries  to  good  account, 
and  fearing  that  his  letters  were  intercepted  and  read,  he  concealed  under  an  out- 
landish foreign  garb  his  real  English-uttered  sentiments  ;  it  was  some  tinje  ere 
this  w"as  discovered.      Thus   the    unintelli^'ible    jargon  —  "  ikaudonomor    butri 


CASES    OF    MOXOM/NIA.  197 

miliesttno  enkuraj  u,  ii  everso  cnkiirajme,  bel  evmc  stilyuis  in  anforkrisf, 
yurstokomzun,  J.  0." — turns  out  to  be,  "I  can  do  no  more  but  try  my  best  to 
encourage  you,  you  ever  so  encourage  me.  Believe  me,  still  yours  in  and  for 
Christ,  yours  to  come  soon,  J.  0." 

Tliese  fruitless  epistles  brought  down  his  further  maledictions  in  the  following 
pointed  declaration  : — 

To  THE  Medical  Profession 

AND 

Co  JI  MIS  SIGNERS     OF     LuNACY, 

Yunr  King  or  Queen  or  any  of  your  Princes,  or  Bishops,  or  Priests, 
or  Judges,  or  Helpers. 
Through  and  by  the  will  of  God  you're  not  safe  one  hour  or  day  so  long  as  I 
and   such   as   1 — J.    0. — is   within   such   Institution   or   any  other   adversity   of 
incarceration. 

(At  the  foot  of  this  was  a  neatly  drawn  outline  of  a  coffin.) 


In  the  following  case  we  have  a  remarkable  instance  of  the  trans- 
formation into  the  monomaniacal  state  upon  the  occurrence  of  epileptic 
seizures  : — 

J.  B.  was  admitted  at  the  age  of  forty-two  years  in  an  acutely  melancholic  state. 
She  was  of  slight  build,  thin,  reduced  and  anaemic,  having  been  in  feeble  health 
since  her  last  confinement,  twelve  months  before.  She  was  not  known  to  be  an 
epileptic.  At  this  period  she  was  greatly  distressed  by  aural  hallucinations,  and 
when  at  home  the  previous  day  had  heard  people  moving  about  beneath  the  floor 
of  the  room  she  occupied,  sharpening  knives  and  saws  to  murder  herself  and 
family ;  all  night  long  she  heard  her  child  crying  distressingly  on  the  staircase, 
and  men  scraping  at  the  walls  of  her  bedroom.  She  was  firmly  convinced  that 
her  soul  was  eternally  lost — could  see  no  escape  from  destruction,  and  under  these 
impressions  she  made  several  desperate  attempts  at  strangulation.  She  refused 
food  and  medicine  most  persistentlj'^,  and  accused  herself  of  every  form  of  iniquity. 
This  despondency  continued  for  some  six  months,  when  the  patient  had  a  series  of 
epileptic  fits,  the  character  of  which  was  not  noted  at  the  time  ;  but  now  an 
entire  change  was  inaugurated  in  her  mental  life — the  depression  abated,  and  she 
assumed  a  cheerful  aspect ;  took  an  intense  interest  in  all  around  her,  and  became 
an  active  and  valued  ward-help.  The  epileptic  seizures  have  occurred  ever  since, 
but  invariably  at  night,  and  with  very  long  intervals,  often  of  years,  between 
the  attacks.  For  many  years  she  has  been  a  typical  example  of  religious  mono- 
mania. The  fits  she  believes  are  caused  hy  the  "working  of  the  spirit — which 
has  been  w^orking  very  powerfully  upon  her  for  some  time — because  the  Father 
has  thought  proper  that  she  should  bear  it  for  the  salvation  of  the  world."  She 
is  still  in  delicate  health,  and  suffers  considerably  at  times  from  migraine.  Always 
smiling  and  cheei'ful,  afiable  with  all  alike,  she  is  a  great  favourite  in  her  ward  ; 
all  who  are  brought  into  contact  with  her  are,  she  believes,  made  eternally  happy 
through  her  instrumentality.  She  is  still  in  idea  a  sufferer — a  Christian  martyr. 
"  She  came  here  because  she  thought  she  had  to  save  all  the  world.  She  knows 
that  Christ  died  to  save  sinners,  but  feels  that  (JJod  has  given  her  that  power. 
She  thinks  that  if  persons  touch  her  it  does  them  good,  and  saves  them.  All  who 
have  come  here  have  come  through  her,  and  she  feels  responsible  for  them.  If 
all  their  souls  rest  on  her,  what  an  account  she  will  have  to  give  at  the  day  of 


198  STATES    OP    MENTAL    ENFEEDLEMENT. 

judgment !     She  cannot  sleep  at  times  because  the  '  spirit  keeps  working  in  her 
like  quicksilver.'" 

Thus  all  former  painful  mental  states  have  been  sublimated  into  this  higher  ideal 
existence.  She  still  answers  to  her  former  name,  but  her  jjcrsonality  is,  as  we  see, 
completely  transformed.  At  times  she  will  state  that  she  feels  she  is  Jesus  Ciirist, 
that  she  existed  before  the  foundation  of  the  world,  and  will  cite  scriptural 
passages  referring  to  the  Messiah,  as  applicable  to  herself.  She  "loves  every- 
body in  the  world,"  and  during  the  evening  is  often  found  at  the  window  singing 
aloud,  "  Hold  the  fort,  for  I  am  coming,"  in  shrill  accents,  with  the  object,  as  she 
says,  of  "helping  those  outside."  She  has  a  gentle,  quiet,  inobtrusive  manner,  has 
the  sweetest  disposition,  spends  much  of  her  time  perusing  her  Bible,  and  is  often 
found  seated  musing,  with  her  hands  crossed  upon  her  breast,  and  an  expression 
of  peaceful  resignation  stirred  into  beaming  animation  when  she  is  addressed. 


E.  T. ,  aged  forty-six  years.  This  patient,  who  is  a  married  woman,  the  mother  of 
six  children  (the  youngest  born  four  years  prior  to  her  admission  into  the  asylum), 
was  then  suffering  from  her  first  attack  of  insanity  of  a  few  weeks'  duration  only. 
She  had  been  confined  to  bed  for  twelve  months,  suffering  from  bronchitis  and 
emphysema,  and  troubles  incidental  to  the  climacteric  period. 

The  history  of  her  case  was  one  of  depression,  groundless  fears,  and  delusions  of 
suspicion  fostered  against  her  family,  who  she  believed  conspired  to  poison  her ; 
under  the  influence  of  these  fears  she  obstinately  refused  food,  and  passed  restless 
nights,  sitting  up  in  bed  continually  praying. 

She  was  regarded  as  at  tlie  climacteric.  Family  history  devoid  of  neurotic  taint. 
On  admission  she  was  extremely  thin  and  wasted.  She  is  short  of  stature,  bony, 
and  of  a  somewhat  masculine  type  ;  she  has  light  blue  eyes,  a  sharp  penetrating 
glance,  and  a  suspicious  demeanour.  vStates  that  her  husband,  daughter,  and 
neighbours  have  conspired  to  remove  her  from  her  home,  that  her  daughter  has 
the  power  of  witchcraft,  and  can  appear  in  various  forms ;  that  her  family  and 
neighbours  introduce  saliva  and  other  disgusting  matter  into  her  food  ;  and  that 
she  has  been  given  gold  dust  and  serpents  to  swallow.  She  stoutly  maintains  these 
statements,  and  declares  that  on  the  previous  night  she  believed  herself  to  be  in 
labour  of  serpents.  She  hears  her  son  and  daughter  whispering  through  tiie  wall, 
and  addressing  her  by  foul  and  abusive  names.  No  visual  hallucinations  are  at 
present  obvious.  The  physical  examination  revealed  general  bronchitis  with 
emphysema,  but  no  consolidation  or  evidence  of  incipient  phthisis,  such  as  her 
appearance  suggested. 

Steady  improvement  occurred  in  her  case,  her  delusions  faded  away,  and  within 
a  month  she  was  regarded  as  convalescent.  Then  occurred  a  sudden  relapse,  in 
which  maniacal  excitement  replaced  the  former  mental  depression,  and  a  downward 
career  of  mental  reductions  has  ensued  unchecked  ever  since.  Her  general  health 
underwent  marked  imi)rovement,  but  slie  always  remained  pale  and  anaemic.  Her 
excitement  was  characterised  by  loud,  abusive,  and  lilasphcmous  language  to  all 
around  her,  and  l)y  a  hostile  ilemeanour  and  threats  of  violence  to  those  who 
approached.  Little  or  no  abatement  of  her  excitement  took  place  under  treatment 
by  succus  conii,  bromide,  with  Indian  hemp,  opium,  or  hyoscyaminc.  Her  con- 
dition, during  the  five  years  succeeding  the  onset  of  attack,  was  that  of  typical 
monomania.  She  would  sit  isolated  from  other  patients  in  a  recess  before  a  win- 
dow, choosing  a  position  where  a  portrait  of  one  of  the  Royal  Princes  hung  opposite 
her.     Here,  decorated  in  fantastic  attire,  her  hair  adorned  with  feathers,  coloured 


MONOMANIA    OF    PKIDE.  19D 

ribbons,  or  mock  diadem,  and  her  dress  decorated  with  coloured  devices,  all  of 
■whicii  had  some  mystic  symbolism  to  herself,  she  would  sit  in  state,  the  embodi- 
ment of  pride  and  arrogance.  From  hence  she  issued  her  mandates  to  the  world 
around,  or  met  those  who  approached  her  with  scornful  defiant  gaze,  together  with 
a  torrent  of  lofty  abuse  and  imperative  orders  to  withdraw  from  her  presence. 
Occasionally  she  would  deign  to  expatiate  on  her  lofty  rank,  would  point  to  the 
porti-ait  of  the  young  Prince,  and  speak  of  herself  as  the  Empress — his  motlier. 
llcr  conversation  was  now  very  incoherent  at  times,  but  was  invariably  tinctured 
by  her  grandiose  delusions.  She  frequently  complained  of  sudden  sharp  pain  in 
the  side,  which  she  attributed  to  having  been  shot  there  by  the  medical  officer. 
On  one  occasion  she  was  heard  to  utter  a  loud  piercing  shriek,  and  was  observed, 
transfixed  witli  horror,  gazing  at,  and  pointing  to,  an  imagined  tragedy,  which  was 
being  vividly  enacted  before  her — "  See  !  see  !  "  she  cried,  "they  have  the  knife  in 
him — look  at  the  blood  ; "  then  she  fell  back  in  her  chair  and  laughed  with 
derisive  laughter. 

Ten  years  after  her  admission  her  habits  are  noted  as  similar,  and  the  mental 
features  as  unaltered.  "She  has  a  forbidding,  arrogant,  threatening  demeanour, 
says — •'!  am  the  Queen — I  will  have  your  blood;'  also  calls  herself  Lady  Skelton. 
and  is  very  angry  if  addressed  by  her  proper  name.  Calls  herself  the  Scotch  Queen 
— the  Queen  of  the  whole  earth — and  in  this  transformation  of  her  own  identity  is 
now  involved  the  personality  of  all  around  her,  to  whom  she  gives  wrong  names. 
Being  accosted  by  her  medical  attendant,  she  asserts — '  I  am  the  Queen,  and  can 
get  you  hanged  ;  that  vagabond  talks  about  the  Queen  ;  you  are  a  tall  young  man, 
and  will  lose  your  life  in  seven  days  if  you  are  not  quick;  I've  been  chopped  to 
bits.'  " 

Twelve  months  later,  evidence  of  phthisis  was  revealed,  and  a  slight  attack  of 
haemoptysis  occurred.  She  complained  of  pain  in  the  lower  dorsal  region,  and 
asserted  that  "that  part  of  my  spine  has  been  cut  out,  and  made  into  jelly  ;  all 
parts  of  my  body  have  been  made  into  jelly  and  thrown  on  the  floor ;  I've  been 
a  doctor  300  years." 

Latterly,  she  has  broken  down  completely  in  health  ;  phthisical  symptoms  have 
been  for  some  time  prominent,  and  occasional  haemoptysis  has  occurred ;  completely 
bed-ridden,  and  a  great  sufferer  from  exacerbations  of  her  chest  symptoms  ;  much 
prostrated  in  health,  pallid  and  emaciated,  she  still  asserts  her  royal  prerogative, 
insists  upon  being  addressed  by  her  formal  title ;  issues  her  mandates  to  her 
courtiers,  princes,  and  statesmen,  with  gestures  of  mock  authority ;  and  still,  at  times, 
becomes  irate  at  the  least  appearance  of  opposition.  There  is  now  considerable 
mental  enfeeblement ;  increasing  incoherence  of  ideas,  and  a  tendency  to  substitute 
unmeaning  words,  and  interpolate  them  in  her  sentences  so  that  they  constitute 
at  times  a  confused  and  unintelligible  jargon.  She  is  now  tractable  and  devoid  of 
all  the  repellent  features  characterising  the  early  stage  of  her  alienation — amiable, 
as  a  rule,  but  still  subject  to  mild  outbursts  of  irritability  and  excitement,  in 
which  her  delusional  notions  become  very  prominent. 

All  these  cases,  we  observe,  are  of  many  years  standing  ;  in  fact, 
monomania  is  a  most  chronic  form  of  insanity,  gradual  in  its  inception, 
and  very  slowly  progressing  towards  general  mental  enfeeblement ; 
the  coherence  of  former  associations  becomes  successively  loosened, 
whilst  the  fictitious  personality  persists  and  erects  itself  skeleton-like 
amidst  the  ruins  of  mind. 


200  STATES    OF    MKXTAL    ENFEEBLEMENT. 

E.  C.  was  admitted  at  the  age  of  thirty-one  years.  Slic  was  a  married  woman 
with  a  family  of  three  cliildrcn.  Subsecmcnt  to  certain  disappointments  in 
money  matters,  she  became  maniacally  excited  two  months  prior  to  her  admis- 
sion, and  had  attempted  suicide  by  cutting  her  throat  with  a  knife.  The 
history,  which  on  most  points  was  defective,  testifies  to  excitement,  incoher- 
ence, a  tendency  to  rhyming  in  her  utterance,  and  several  gross  delusions.  For 
some  years  she  had  suffered  from  spinal  curvature,  which  was  found  to  be  in 
the  dorsi-lumhar  region,  with  a  convexity  strongly  directed  backwards  and  to  the 
left.  Her  excitement  abated  in  the  course  of  some  six  months— she  became  calm, 
orderly,  and  industrious.  With  this  emotional  calm,  however,  it  was  found  that 
she  was  the  subject  of  fixed  delusional  notions,  all  of  which  suggested  suspicion 
and  persecution  upon  the  part  of  her  neighbours  and  those  immediately  associated 
with  her.  These  delusions  were  of  very  varied  nature.  She  believes  that  by  the 
agency  of  machinery,  concealed  beneath  the  building,  she  is  subjected  to  constant 
torture  at  night — her  body  "  screwed  up"  and  her  flesh  torn  from  the  bones,  and 
that  she  is  "rocked  in  her  bed  by  invisible  power."  Believes  she  has  a  second 
body  beneath  the  floor,  which,  when  operated  upon,  causes  suffering  in  her  tcaX 
body.  "  When  they  tie  the  rope  round  the  other  body  down  yonder  (pointing  to 
the  floor)  my  bowels  are  screwed  up  and  my  bones  crushed ;  they  (her  persecutors) 
often  fetch  me  to  Halifax  from  Wakefield  by  electricity,  and  they  have  taken  my 
children  out  of  their  graves  and  dragged  them  about  for  one  and  twenty  years." 
Aural  hallucinations  were  frequent  phenomena,  and  she  was  often  detected  listen- 
ing at  the  window  to  imaginary  voices,  receiving  messages  from  distant  towns, 
holding  communication  with  her  daughter,  &c.  Associated  with  these  ideas  of 
cruelty  and  persecution,  there  were  feelings  of  great  self-importance  and  authority 
encroached  upon.  The  as5'lum  buildings  were  her  possession,  and  the  staff  of 
officers  her  subordinates,  whom  she  threatened  with  instant  dismissal  if  they 
ne^^lected  her  commands.  She  invariably  met  the  medical  oflBcer,  day  by  day, 
with  the  authoritative  order  for  her  dinner,  and,  as  invariably  after  her  meal, 
demanded  a  cab  to  take  her  home.  When  questioned  upon  dates,  it  was  noted  that 
she  was  always  a  j'ear  in  advance,  although  correct  as  to  the  day  of  the  month. 
This,  upon  examination,  was  found  to  depend  upon  the  delusion  that,  "in  the  year 
1865  {ichen  she  icas  admitted  into  the  asylum),  they  (her  persecutors)  did  not  add 
the  figure,  but  allowed  two  years  to  slip  by  as  186G,  for  reasons  best  Jcnovn  to  them- 
selves." She  is  sadly  perplexed  at  times  about  the  quantity  of  food  consumed  by 
her  fellow-patients,  believing  that  the  institution  is  supported  by  her  bounty. 
Between  the  years  1884  and  18SG,  she  suffered  from  three  very  sudden  and  pro- 
longed attacks  of  acute  maniacal  excitement  in  which  she  was  utterly  incoherent, 
noisy,  voluble,  and  was  greatly  reduced  by  insomnia  and  restlessness.  In  the 
intervals  between  such  attacks,  her  delusions  remain  unchanged.  She  refers 
to  "  the  annoyance  that  is  kept  in  the  wall ;  they  can  move  it  elsewhere,  or 
she  would  have  had  the  wall  down  long  since.  Evil  trauslatings  issue  from  the 
wall  to  her  back.  Persons  act  on  her  by  electricity,  so  that  if  she  be  walking, 
they  can  throw  her  flat  down  on  her  face ;  it  is  their  interference  that  has  caused 
the  deformity  in  her  back." 


PERSISTENT    MENTAL    INSTABILITY.  201 

RECURRENT  INSANITY. 

Contents.— Definition — Establishment  of  Labile  E(nnlibriura— Prevalence  at  Sexual 
Decadence — Heredity — luHuence  of  Neurotic  Heritage  and  of  Ancestral  Intem- 
perance—Atavism— Recurrence  in  the  Congenitally  Defective  Subject— Morbid 
Excitement  and  the  Moral  Imbecile— Alternations  of  Excitement  and  Stupor- 
Hysteria  and  Menstrual  Irregularity-  Eroticism  {A.  S.,  M.  A.  J/. )— Eecurrence 
in  Adolescence  [M.  C.  (K.)— riecurreuce  at  the  Climacteric  (//.  0.)— at  the  Senile 
Epoch  (/.  <S.)— in  Puerperal  Subjects  {M.B.)—m  Traumatic  Insanity  (Z>.  X.)— 
Morbid  Impulsiveness — Hallucination  and  Delusion  (./.  B.) — Prognosis — 
Treatment. 

All  forms  of  insanity  are  prone  to  recur ;  from  whatever  source  the 
unstable  condition  of  the  nervous  centres  is  derived,  whether  from 
inherited  neurotic  tendencies,  acquired  vices,  or  physical  ailments,  all 
alike  (even  the  most  recoverable  forms)  have  such  a  predisposition, 
intensified  by  the  occurrence  of  an  attack.  It  is  a  general  law  that 
the  more  frequently  a  centre  discharges  its  energy,  the  more  sensitive 
to  excitation  becomes  the  mechanism,  and  the  more  readily  the  dis- 
charge repeats  itself.  Hence,  the  extensive  cortical  discharges  which 
account  for  the  reductions  of  insanity  will,  even  in  the  most  complete 
recoveries,  tend  to  foster  a  similar  hyper-sensitiveness,  and  a  labile 

equilibrium  of  the  parts  previously  involved. 

By  recurrent  insanity  we  mean  a  type  of  mental  disturbance  in 
which  there  is  an  establishment  of  this  labile  equilibrium  ;  and  the 
conditions  under  which  such  recurrence  is  brought  about,  together 
with  the  essential  nature  of  the  attack,  form  the  subject  of  our  inquiry. 
In  the  first  place,  it  must  be  remembered  that  a  neurotic  inheritance, 
however  strong,  does  not  necessarily  result  in  recurrent  insanity  ;  and, 
in  the  next  place,  it  should  be  noted  that  simple  relapses  of  insanity, 
which  may  occur  at  diflTerent  periods  throughout  life,  do  not  imply 
the  existence  of  the  neurotic  type  here  alluded  to  as  recurrent  insanity. 

Recurrence,  with  long  intervals  of  repose,  is  not  the  characteristic 
of  this  type,  but  rather  the  rapid  succession  of  attacks,  each  followed 
by  an  apparent  complete  convalescence.  "  Notwithstanding  the 
authentic  instances  of  recurrent  insanity  showing  intervals  of  lucidity 
for  very  long  periods,  so  that  the  disease  is  known  to  be  dormant  for 
years,  it  is  by  no  means  to  be  inferred  that  every  case  that  is  a  second 
attack  belongs  to  such  a  categoxy"  (Sankei/).*  A  large  section  of  the 
insane  community  is,  therefore,  constituted  by  these  unfortunate  ones, 
who  pass  many  years  of  their  life  between  an  asylum  and  their  home 
during  frequent  alternations  of  sanity  and  insanity.  Those  not  con- 
versant with  statistics  of  insanity  have  but  a  faint  notion  of  the  miserable 
existence  of  such  victims.  The  following  scheme  of  some  fifty  recurrent 
cases  amongst  women  will  exhibit  this  fact  in  a  striking  manner : — 
*  Lectures  on  Mental  Disease,  p.  179. 


'202 


persistknt  mkntal  instability. 
Table  of  Female  Recurrents. 


Number  of 
Attacks. 

Occurring  between 
the  Ago  of 

Representing 
lutorval  of 

Number  of 
Attacks. 

Occurrins  between 
the  Ago  of 

Representing 
lutorval  or 

5 

16  and  32  y  IS. 

16  yrs. 

Several 

3 1  and  36  yrs. 

5  yrs. 

3 

17    „    20   „ 

•i   „ 

5 

32   „   48   „ 

16   „ 

3 

17   „   21   „ 

4  „ 

8 

32   „    42   „ 

10   „ 

Several 

IS   „    30   ,, 

12   „ 

5 

33   „   37   „ 

4   „ 

3 

19   ,,   24   „ 

5   „ 

4 

35   „    50  ,, 

15   „ 

3 

20  ,,    21    „ 

1    „      i 

6 

35   ,,   53   „ 

18   „ 

3 

20   „   25   „ 

5   „ 

4 

35   „   48   ,, 

13   „ 

3 

20  „    33   „ 

13   „ 

3 

39   „   46   „ 

7   „ 

3 

19   „   28   „ 

9   „ 

5 

38   „    50   „ 

12  „ 

4 

24   „   44   „ 

20   „ 

3 

38   „   40  „ 

3 

23   „   25   „ 

2 

4 

38   ,,   56   „ 

18  „ 

5 

24   „    36   „ 

12   „ 

3 

40   ,,   45   „ 

5  „ 

4 

25   „    35   ,, 

10  ,, 

3 

42   „   59   „ 

17  „ 

3 

26   ,,   40   ,, 

14   „ 

7 

43   „   53   ,, 

10  .. 

5 

28   „   45   „ 

17  „ 

5 

43   „   58   „ 

15   „ 

4 

29   „   42  „ 

13  „ 

Several 

43   „   58   „ 

15   „ 

5 

29   ,,   52   „ 

23   „ 

6 

42   „   51    „ 

9   „ 

3 

29   „   33   „ 

4   ,, 

4 

41   „   58   „ 

14  „ 

3 

30   „    41    „ 

11    „ 

3 

47   ,,   55  ,, 

s  „ 

4 

30  „   44   „ 

14  „ 

3 

46   „   50   „ 

4   „ 

4 

30   „   42   „ 

12   „ 

4 

48   „    63   „ 

15   „ 

6 

30   „   43   „ 

13   „ 

5 

50  „    53   ,, 

3   „ 

3 

30   „    35   ,, 

5   ,, 

3 

50   „    58   „ 

8   „ 

3 

30   „   42   „ 

12   „ 

5 

51   „   54   „ 

3   „ 

3 
4 

1 

30   „   35   „ 

30   ,,    55   ,, 

5   „ 
25   „ 

3 

Total,  .00 

Persons. 

lS3(TSevei-alj 

Attacks. 

54   „   56   „ 

2  „ 

When  dealing  with  the  insanity  incident  to  the  periods  of  puberty 
and  adolescence,  it  will  be  seen  that  recurrences  are  not  frequent  in 
the  proper  acceptation  of  the  term  ;  up  to  the  stage  of  complete  con- 
valescence relapses  are  peculiarly  prone  to  occur,  but,  once  the  cure  is 
complete,  a  recurrence  of  insanity  is  not  frequent,  sixteen  instances 
only  of  a  third  or  fourth  attack  being  given  in  277  cases. 

Recurrent  forms  of  insanity  are  far  more  prevalent  in  adult  life,  and 
increase  gradually  towards  the  decline  of  manhood  and  womanhood. 
In  men,  quite  one  half  the  cases  of  recurrent  insanity  occur  after  forty 
years  of  age ;  and  out  of  a  total  of  G6  individuals  so  affected,  49  had 


INCIDENCE    OF    IlECURUENT    INSANITY. 


203 


passed  their  thirtieth  year  of  life ;  similarly  in  women,  we  find  that 
nearly  half  the  cases  cover  the  period  of  life  between  forty  and  fifty- 
five,  which  may  be  safely  taken  as  the  limit  of  the  climacteric  period. 
In  fact,  the  period  of  life  between  forty  and  sixty  years  in  the  female 
is  peculiarly  susceptible  to  this  form  of  mental  derangement,  being  the 
period  involved  in  sexual  decadence  and  the  advance  of  senility.  In 
man  this  feature  is  not  so  apparent,  there  being  other  influences, 
as  we  shall  see  later  on,  which  tend  to  beget  in  him  such  recurrent 
attacks  at  a  somewhat  earlier  period  of  life. 


Respective  Age  in  Qcinquennial  Periods,  in  164  Cases  of 
Recurrent  Insanity, 


Age. 

Males. 

Females. 

Up  to  25  years, 

10 

9 

„     30     „ 

7 

8 

„     35     „ 

7 

9 

„     40     „ 

9 

8 

,.     45     „ 

7 

21 

„     50    „ 

9 

9 

„     55     „ 

5 

13 

„     60    „ 

4 

17 

,.     65     „ 

3 

4 

„     70    „ 

5 

66 

98 

Who  are  the  subjects  most  liable  to  this  form  of  mental  disturbance? 

They  have  a  strongly  stamped  hereditary  history  of  insanity ; 

the  parentage,  when  facts  are  procurable,  revealing  attacks  of  insanity 
often  along  both  paternal  and  maternal  lines.  It  is  also  notable,  that 
in  a  large  proportion  of  cases,  we  find  the  history  of  ancestral  insanity 
attached  to  the  grandparents,  or  the  collateral  line  of  uncles  and 
aunts,  significant  of  a  more  remote  origin  for  the  neurosis.  The  actual 
proportion  of  cases  revealing  strongly  marked  hereditary  features 
(often  involving  several  members  of  the  subject's  ancestry)  amounts  to 
36  per  cent.;  but,  in  12-5  per  cent,  only  was  it  discoverable  that  the 
subject's  parents  had  been  insane. 

In  the  next  place  we  observe  that  other  neuroses,  notably  epilepsy, 
are  absent  in  the  antecedent  history.  Chorea,  hysteria,  epilepsy, 
hemiplegic  seizures  are  prone  to  occur  in  the  ancestry  of  a  certain 
class  of  the  insane,  as  was  seen  to  be  the  case  in  the  insanity  of  female 


204:  PERSISTENT    MKN'TAL    INSrAHILITY. 

adolescents,  wlici'c  20  per  cent.  I'evealed  this  predisposition  ;  but  such 
a  neurotic  history  is  attached  to  only  4-4  per  cent,  of  the  recurrent 
forms  of  alienation. 

Again,  parental  intemperance— a  potent  source  of  all  forms  of 
convulsive  neuroses — is  revealed  in  11  •!  per  cent,  (males  89,  and 
females  12-6),  or  over  tioo-tliirds  the  proportion  of  cases  shown  by 
adolescent  forms  of  insanity ;  and  in  80  per  cent,  of  such  instances 
of  parental  intemperance,  the  fatJier  was  at  fault.  This  fact  is  a 
suggestive  one,  and  the  question  naturally  arises — why  one  form  of 
insanity  should  appear,  as  the  result  of  an  insane  inheritance,  and 
another  as  the  heritage  from  epileptic  parents  or  grandparents,  or  as 
the  outcome  of  parental  drink  *?  If  we  accejit,  as  we  have  reason  for 
so  doing,  the  dictum  that  the  hereditariness  of  insanity,  like  the 
heredity  of  other  pathological  tendencies,  is  restricted  by  sex  and 
age,  it  may  reasonal)ly  be  assumed  that  the  neuroses  of  early  life — 
chorea,  hysteria,  epilejDsy — will  be  especially  prone  to  reassert  them- 
selves also  at  a  similar  epoch  in  the  life  of  the  offspring ;  and  that, 
thei'efore,  an  epileptic  father  or  grandfather  who  became  epileptic  at 
jmherty  Avill  be  liable  to  transmit  to  his  sons  a  morbid  tendency  which 
appears  as  epilepsy  or  the  like  at  the  adolescent  period.  Insanity,  on 
the  other  hand,  is  not  a  disease  of  early  years,  and,  as  we  have  seen, 
is  far  more  frequent  towards  the  middle  period  of  life  ;  hence  we 
might  expect  its  appeai'ances  as  an  inherited  affection  to  be  regulated 
by  the  same  laws.  This  is  seen  to  be  the  case  with  the  recurrent 
form,  which  is  strongly  inherited,  and  which  conforms  to  the  law  of 
insanity  in  general,  in  being  most  prevalent  at  the  middle  epoch  of 
life.  Adolescent  forms,  however,  must  be  differently  accounted  for, 
and  may  indeed  with  justice  be  conceived  of  as  the  morbid  expression 
of  an  inherited  neurosis  of  the  epileptic  type — epilepsy  in  the  collateral 
or  direct  line  tending  to  issue  in  insanity;  often  even  by  atavic  descent. 
It  is  generally  conceded  that  alcoholic  craving  is  often  an  inherited 
condition,  as  in  the  form  of  "  dipsomania ; "  and  that  parental  intem- 
perance frequently  results  in  the  imbecility,  idiocy,  epilepsy,  or  deaf- 
mutism  of  the  offspring — all,  we  observe,  indications  of  arrested 
development  or  disease  in  early  life.  To  this  category  we  may  add 
adolescent  insanity,  which  is  especially  apt  to  be  engendered  in  the 
offspring  of  those  addicted  to  heavy  drinking,  under  certain  physio- 
logical conditions  and  the  operation  of  other  excitants. 

To  revert,  however,  to  the  recuri-ent  form — the  heredity  observed 
in  such  subjects  is  more  often  atavic  than  direct — its  frequent 
appearance  in  the  collateral  line  of  uncles  and  aunts,  being  strong 
presumptive  evidence  in  favour  of  an  atavism  even  where  no  other 
record  exists.    Its  comparatively  later  development  than  the  adolescent 


INTEMPERANCE    AND    RECUKRENT    INSANITY.  205 

form  appears  to  be  governed  by  the  law  of  limitation  by  age,  wliich 
is  enforced  in  most  hereditary  atiections  ;  the  ancestral  affection 
occurring  in  adult  life  tends  to  reproduce  itself  at  the  same  epoch. 
Parental  intemperance  declai-es  itself  almost  exclusively  on  the  father's 
side,  but  is  by  no  means  a  prominent  predisposing  element.  The 
neurotic  temperament  of  these  subjects  is  revealed  in  an  undue  excita- 
bility, and  a  defective  moral  control,  exhibited  often  in  ungoverned 
passion,  and  generally  mobile  emotional  states ;  occasionally,  such  lack 
of  control  amounts  to  mild  forms  of  imbecility  of  the  moral  type — 
congenital  defects  occurring  in  some  12  per  cent,  of  such  cases.  For 
the  first  start  in  life,  such  organisations  may  readily  adapt  themselves, 
and  the  period  of  puberty  and  adolescence  passes  by  without  serious 
risk;  but,  as  the  complexity  of  life  increases  in  the  ever  more  complex 
environment,  corresponding  developments  do  not  occur,  and  adapta- 
tion is  at  fault.  The  organism  but  awaits  some  exciting  cause  which, 
as  with  a  fulminate,  determines  the  attack  of  insanity.  If  a  female, 
the  period  of  gestation  or  parturition  may  so  act,  or,  still  more  forcibly, 
the  epoch  of  the  menopause ;  if  a  male,  alcoholic  indulgence  is  a  most 
potent  agency  in  causing  the  fui'ther  reduction  which  issues  in  acute 
insanity. 

The  climacteric,  as  we  have  already  .stated,  is  a  period  prone  to 
induce  and  foster  a  craving  for  stimulants ;  and  hence,  we  find  that 
13-7  per  cent,  of  female  recurrents  were  addicted  to  intemperate 
habits,  whilst  30  per  cent,  of  the  male  recurrents  had  succumbed 
to  this  vice.  In  short,  the  subjects  prone  to  recurrent  insanity  are, 
in  general,  congenitally  predisposed  by  defective  mental  organisation, 
and  inherit  a  strong  parental  or  atavic  tendency  to  insanity,  which 
usually  appears  upon  the  indulgence  in  alcoholic  stimulants,  or  at 
the  later  critical  epochs  of  life — notably  the  climacteric  and  senile 
decrepitude. 

Dr.  Sankey,  on  the  other  hand,  regards  the  periodicity  of  recurrent 
insanity  as  bringing  this  disease  into  close  alliance  with  epilepsy;  his 
statement  is  to  this  effect : — "  By  the  very  character  of  periodicity 
(a  character  of  the  utmost  importance  in  their  pathology),  they  are 
allied  to  epilepsy,  and  in  certain  cases  actually  terminate  in  well- 
marked  symptoms  of  that  disease;  especially  when  our  views  of  epilepsy 
include  all  the  phenomena  and  variation  of  the  j^et'd  mal,  now  generally 
classed  with  true  epileps3^"  * 

Nature  of  the  Attack. — The  seizui-e  varies  as  to  its  symptoms 
and  course  with  the  exciting  cause  at  work,  and  the  period  of  life 
when  it  occurs.  There  may  be' mild  maniacal  excitement,  without 
obvious  delusional  perversion ;  or  the  attack  may  be  characterised  by 

*  Loc.  cil.,  p.  179. 


20G  PERSISTENT    MENTAL    INSTAUILITV. 

delusions  of  sns|iicioii  unci  persecution  ;  or  by  an  ordinary  lijpemania, 
■with  delusions  of  a  depressant  nature.  Maniacal  conditions  certainly 
prevail  in  the  earlier  and  later  periods  of  life — in  adolescence  and  in 
senility ;  whilst  the  climacteric  cycle  usually  calls  forth  emotional 
depression  and  mehincholic  delusions.  Of  subjects  prone  to  recurrent 
seizures  of  nuuiia  or  melancholia,  the  more  important  are  cases  of 

Congenital  mental  defect.  Insanity  with  menstrual  deraogenient. 

Adolescent  insanity.  Puerperal  insanity. 

Alcoholic  insanity  (acute).  Climacteric  insanity. 

Traumatism  (cranial  injur}').  Senile  insanity. 

Epileptic  subjects,  in  whom  recurrent  seizui'es  are  frequent,  are 
necessarily  excluded  here  by  their  intrinsic  importance,  and  will  be 
considered  apart. 

Recurrence  in  Congenitally  Defective  States.— Those  whose 

mental  organisations  ai'e  congenitally  defective  in  both  sexes  are  pro- 
verbially subject  to  passionate  explosiveness,  to  rapid  alternations  of 
mood,  and  to  other  indications  of  great  instability.  Such  cases  are  often 
misjudged,  the  normal  undisturbed  state  being  one  of  striking  placidity 
and  great  amiability,  which  seems  to  render  it  highly  improbable  that 
the  passions  will  so  readily  assume  the  opposite  exti'eme ;  but,  so  it  is, 
that  such  extremely  amiable  natures  will  pass,  upon  the  most  trivial 
disturbance,  to  a  bitterness  and  a  passionate  demonstrativeness  often 
exhibiting  an  inherent  cruelty  and  viciousness. 

"With  lack  of  inhibitory  "staying"  power,  sucli  individuals,  as  before 
stated,  meet  a  severe  trial  during  the  adolescent  period  of  life  ;  but,  if 
they  do  not  succumb  to  insanity  at  this  epoch,  they  are  still  subject, 
upon  the  occurrence  of  trivial  agencies,  to  an  attack  of  insanity  at  any 
subsequent  period  of  life. 

The  agencies  which  are  thus  potent  towards  such  an  issue  are  alco- 
holic and  sexual  excess,  masturbation,  and  indulgence  in  morbid  excite- 
ment of  any  class.  jNIasturbation,  especially,  lays  the  groundwork  for 
an  attack  of  insanity  by  the  nutritive  changes  induced  in  the  nervous 
centres — their  exhaustion  and  the  ultimate  impoverishment  of  blood. 
If  this  vice  be  associated  with  alcoholic  indulgence,  the  effect  is  vastly 
augmented,  and  the  worst  forms  of  recurrent  insanity  occur.  Another 
frequent  source  of  the  attack  is  the  powerful  influence  of  morbid  emo- 
tional excitation — sensational  plays,  sensational  literature,  "  revival  " 
services,  "Salvationist"  crusades;  all  have  much  to  answer  for  in 
their  effect  upon  the  moral  imbecile,  ;nul  those  lacking  in  moral 
control.  Menstrual  derangements,  again,  foster  in  the  congenitally 
defective  an  explosiveness  which  may  issue  in  an  attack  of  insanity. 
In  all  these  cases  the  agency,  whether  it  be  menstrual  irregularity, 


STUPOR    AND    HYSTERIA    IN    RECURRENT    INSANITY.  207 

masturbation,  sexual  excess,  alcoliolic  intoxication,  or  undue  nervou?> 
excitement  from  moi'al  causes,  acts  by  occasioning  a  malnutrition  of 
the  central  nervous  system,  already  j>redisposed  to  insanity  through 
a  neurotic  inheritance,  expressed  in  a  defective  mental  organisation. 

In  the  male  subject,  so  constituted,  the  attack  of  insanity  is  almost 
invariably  one  of  excitement,  characterised  by  noisy,  boisterous 
humoui',  mischievous  conduct,  destructiveness,  viciousness,  and  out- 
bursts of  violence.  Diurnal  quiet  often  alternates  with  nocturnal 
excitement — the  nights,  in  such  cases,  being  spent  in  noisy,  incoherent 
rambling,  and  often  prolonged  insomnia.  Frequent  relapses  of  excite- 
ment are  prone  to  occur  before  convalescence  is  more  permanently 
established.  Should  masturbation  complicate  the  case,  the  subject 
becomes  a  prey  to  delusions  of  suspicion,  and  altGPnations  Of  excite- 
ment and  stupor  will  often  take  place. 

In  the  female  subject,  the  attack  of  insanity  occurring  is  also  one  of 
acute  excitement,  where  mild  forms  of  moral  imbecility  or  naturally 
defective  inhibition  are  maintained.  The  type  is  usually  that  of 
so-called  hysterical  insanity,  I'eproducing,  as  it  does,  many  promi- 
nent hysteric  symptoms. 

The  typically  hysteric  subject  is  generally  the  subject  of  menstrual 
irregularities,  as  in  the  following  cases  : — 

A.  S.,  aged  twenty  years,  mill-hand,  admitted  May,  1870.  A  cousin  was  insane 
and  epileptic.  This  patient  was,  in  1868,  placed  in  Morningside  Asylum,  and 
remained  there  five  months,  being  discharged  at  the  request  of  her  friends, 
although  probably  not  recovered.  Her  second  attack,  for  which  she  was  treated 
here,  was  characterised  by  violent  eroticism ;  she  conversed  incessantly  on 
marriage,  &c.  Its  duration  was  short,  but  she  was  not  considered  sufficiently 
stable  to  be  discharged  under  nine  months.  The  menstrual  function  had  been 
regularly  performed  as  regards  time,  but  in  amount  variable,  occasionally  rather 
profuse,  more  often  there  was  amenorrhoea.  In  less  than  two  years  she  again 
required  restraint ;  the  catamenia  having  ceased,  she,  about  a  month  afterwards, 
became  restless,  sleepless,  and  excitable,  prone  to  destructiveness,  and  very 
indecent  both  in  sjieech  and  demeanour.  When  admitted,  she  was  somewhat 
maniacal,  but  intensely  erotic — betraying  much  perverted  sexuality.  Showed 
evidence  of  the  existence  of  aural  hallucinations.  She  improved,  and  was  dis- 
charged under  a  twelvemonth.  A  fourth  recurrence  of  msanity  took  place 
twenty  months  later,  the  catamenia  being  on  this  occasion  regular.  Only  slight 
premonition  was  given,  and  the  patient  became  suddenly  excited,  violent,  inco- 
herent, with  much  religious  matter  mixed  up  in  her  ravings;  but  the  sexual 
feeling  only  displayed  itself  once  in  three  weeks,  during  which  time  the  mania 
subsided.  Eroticism  was  alone  manifested  in  connection  with  irregularity  of 
menstrual  function,  which  occurred  later ;  it  did  not  cease  until  the  catamenia 
had  resumed  their  normal  characters.     Discharged  in  thirteen  months. 

Another  relapse,  eight  mouths  subsequently,  was  purely  maniacal  in  kind ; 
there  was  rambling  at  tirst  upon  religious  topics,  slight  or  no  evidence  of  eroticism, 
and  no  added  irregularity  of  menstrual  performance — which,  it  was  stated, 
generally  erred  on  the  aide  of  insufficiency.     Seven  months  accomplished  a  cure. 


208  PERSISTEN'T    MENTAL    IXSTABILITV. 

The  sixth  and  last  admission  occurred  eight  months  later ;  menstrual  derange- 
ment had  again  preceded.  The  condition  was  one  of  simple  mania,  with  great 
religiosity,  but  without  sexual  characters  predominating.  Convalescence  occurred 
immediately  the  catamenial  irregularity  was  remedied.    Sent  out  in  seven  months. 


M.  A.  M. ,  aged  twenty  years,  domestic  servant,  admitted  May,  1881,  Patient's 
father  and  mother  eccentric.  No  insane  relations.  M.  A.  M.  was  a  girl 
of  steady,  industrious,  and  healthy  habits,  until  one  year  before  the  above  date, 
about  which  time,  it  was  said,  she  had  two  transient  attacks  of  mental  disorder. 
One  week  ]irior  to  admission  here,  she  became  altered  in  manner,  depressed  about 
religious  subjects,  restless,  excitable,  and  ^'iolent.  When  received  into  the  asylum, 
she  was  in  a  state  of  acute  mania — boisterous,  mischievous,  and  of  rather  dangerous 
and  treacherous  propensities  ;  she  remained  in  this  condition  for  a  few  days,  when 
she  gradually  settled  down  and  behaved  quietly  and  rationally,  excepting  for  a 
little  chance  flightiness,  during  three  weeks — then  gave  way  to  a  burst  of  unruly 
excitement,  showing  much  erotic  tendency  and  depravation  of  habits.  There  was 
no  catamenial  irregularity.  She  merited  her  discharge,  recovered,  five  months 
after  admission — and  remained  outside  in  domestic  service  for  fifteen  months, 
during  the  last  five  weeks  of  which  she  began  to  fail  in  general  health  and  to 
become  wild,  restless,  noisy,  and  turbulent.  Her  manner  on  admission  varied 
between  excitability  and  garrulousness,  and  obstinate  reticence  and  brooding. 
The  maniacal  state,  with  considerable  prominence  of  sexual  feeling,  continued  for 
a  week  and  then  began  to  subside.  On  a  few  occasions,  however,  she  had  slight 
relapses  of  excitement,  at  times  preceded  bj'  gloomy  reserve.  On  the  whole, 
behaved  in  an  orderly  and  industrious  manner,  and  after  seven  months'  lapse,  was 
convalescent  and  sent  out.  Catamenia  very  irregular.  It  appeared  that  from  the 
period  of  her  discharge  to  that  of  her  readmission,  two  months  later,  the  patient 
had  been  flighty  and  excitable,  and  became  unmana:_'eable.  Her  symptoms  on 
this  third  recurrence  were,  in  the  main  points,  repetitions  of  those  exhibited  during 
previous  attacks,  including  some  erotic  display;  and  the  progress  of  her  case  wais, 
in  most  respects,  similar  to  that  of  the  preceding  one,  but  uninterrupted  by 
relapses,  although  the  jjatient's  irritable  intolerance  of  supervision  rendered  need- 
ful much  tact  in  her  management.  She  remained  excited  at  night  for  some  time, 
after  her  behaviour  during  the  day-time  had  improved;  the  erotic  tendencies 
ceased  shortly  after  her  admission.  She  was  quite  convalescent  in  thirteen 
months;  but  was  only  outside  the  asylum  for  two  weeks,  having  had  a  fourth 
recurrence  of  mania  almost  immediately  after  leaving.  Sleeplessness,  wandering, 
excited  and  violent  conduct  prevailed,  and,  when  put  under  care,  she  was  very 
maniacal,  gay,  flippant,  and  inattentive;  j-et,  as  on  previous  occasions,  recognis- 
ing all  with  whom  she  had  previously  been  brought  into  contact.  In  the  following 
three  mouths,  frequent  relapses  into  a  turbulent  condition  interrupted  longer 
periods  of  industry  and  quiet.  For  twenty  months  she  remained  free  from  any 
outburst,  and  again,  for  three  months,  passed  through  a  phase  of  excitement, 
characterised  by  silly  and  indecent  talk,  gay  carelessness,  and  violent  tendencies. 
For  the  last  year,  no  relapse.     Still  an  inmate. 

Recurrence  in  Adolescent  Cases. — Adolescence  occasionally 

ushers  in  recurrent  attacks  of  mania — three  or  four  such  seizures, 
between  the  ages  of  seventeen  and  twenty-five  years,  being  sometimes 
witnessed.     In  all  such  instances,  the  symptoms  reproduce  overaud, 


RECURRENT   INSANITY   IN    ADOLESCENCE.  209 

over  again  the  features  (already  delineated)  of  insanity  occurring  at 
this  epoch.  Recurrent  mania  originating  during  adolescence  is  of 
very  ominous  portent ;  the  prognosis  is  exceptionally  unfavourable,  in 
so  far  that  it  indicates,  for  a  large  j)roportion  of  cases,  a  congenitally 
defective  mental  organisation ;  that  many  others  are  doomed  to  succes- 
sive attacks  beyond  this  period  of  life;  and  that  the  rest  remain  chronic 
residents  of  our  asylums,  or  are  discharged  as  partial  "  recoveries " 
only — or  their  recovery,  if  at  all  complete,  takes  place  after  a  protracted 
illness,  often  embracing  successive  relapses. 

M.  C.  W.,  aged  eighteen,  single;  a  tall,  well-proportioned  girl,  of  somewhat 
delicate  aspect,  feeble  muscular  development,  dark  brown  hair,  light  blue  eyes, 
complexion  fair,  expression  bright,  animated,  and  intelligent.  For  some  time  jiasb 
she  has  been  in  delicate  health,  and  is  distinctly  anfemic.  She  brings  with  her 
a  strong  neurotic  heritage ;  her  maternal  grandmother  was  twice  under  treatment 
at  an  asylum,  her  mental  balance  overtlirown  each  time  by  "some  love  affair;" 
her  own  mother  is  highly  eccentric;  and  she  herself  has  been  regarded  as  very 
unstable,  flighty,  and  erratic.  The  lungs  and  heart  are  healthy,  and  the  alimen- 
tary system  free  from  derangement.  The  catamenia  have  been  excessive  of  late, 
and  of  fortnightly  occurrence.  For  a  month  prior  to  her  attack,  the  patient  had 
been  attending  exciting  religious  services,  "revival  meetings,"  and  had  been 
excited  over  these  subjects,  talking  much  in  a  religious  strain.  The  attack 
occurred  a  few  days  before  admission;  she  became  acutely  maniacal,  garrulous, 
and  incoherent.  On  removal  to  the  workhouse  infirmary,  she  tore  down  the  pads 
of  the  padded  room,  was  extremely  violent,  and  her  conduct  most  outrageous. 
When  brought  to  the  asylum,  the  maniacal  condition  was  still  acute;  she  was 
good-tempered,  jovial,  mischievous,  talked  incessantly,  and  gambolled  from  subject 
to  subject,  but  could  carry  on  a  connected  discourse  on  closely  questioning  her,  and 
insisting  i;pon  a  reply.  She  had  a  flippant  air,  was  pert  in  her  remarks,  and 
shrewd.  Appeared  quite  unaware  of  the  nature  of  her  surroundings.  Left  to 
herself,  she  talked  incoherently,  interspersing  her  remarks  with  frequent  allusions 
to  "  angels,  hell,  and  devils,"  saying  that  she  heard  "  trains  whistling  telegrams 
to  heaven,  when  at  the  workhouse. " 

Half  an  ounce  of  the  succus  conii  was  ordered  twice  daily,  and  chloral  was 
given  occasionally  at  night  to  secure  sleep.  In  four  days  it  is  noted — "  Much 
more  composed  and  rational ;  sleeps  well,  and  is  trying  to  employ  herself  usefully ; 
has  not  yet  lost  the  flightiness  of  behaviour  and  demeanour;  appetite  good."  In 
a  fortnight  she  was  in  the  "convalescent"  ward.  A  month  subsequent  to  her 
admission  a  complete  relapse  occurred,  characterised  as  before  by  noisj'^,  boisterous 
behaviour,  great  hilarity,  pertness,  and  occasional  insolence ;  her  nights  were  not 
disturbed  by  excitement.  Conium  (succus  conii)  was  given  in  one  ounce  dose 
twice  daily,  and  towards  the  middle  of  the  month  the  excitement  abated,  and  she 
became  sufficientlj'  staid  to  attend  the  weekly  dance.  Exactly  a  month  after  the 
jirst  rclapxe,  a  second  occurs,  in  which  she  again  proves  boisterous,  \aolent,  and 
destructive;  her  bodily  health,  however,  has  been  progressively  improving  since 
her  admission.  It  was  clearly  seen  that  her  relapses  were  coincident  ivith  the 
menstrual  periods  ;  but  the  occurrence  of  the  next  period  was  passed  witiiout  any 
mental  disturbance,  and  she  Avas  discharged,  recovered,  a  few  weeks  subsequently. 

Six  years  later,  that  is,  when  twenty-four  years  of  age,  this  patient  again  became 

u 


2T0t: 


PERSISTENT    MENTAL    INSTABILITY. 


an'  inmate  of  our  wards.  She  had  kept  well,  and  regnlarl}'  employed  as  a  dyer 
during  the  interval,  when,  upon  tlie  occurrence  of  a  pecuniary  loss  by  her  mother, 
the  daughter  again  succumbed  to  her  inherited  weakness.  She  was  maniacally 
excited,  though  not  in  an  extreme  degree.  There  was  marked  elevation  of  spirits; 
she  was  well-satisfied,  gay,  flippant,  and  saucy.  She  talked  loquaciously,  very 
irrationally,  and  incoherently.  Evidently  has  a  strong  propensity  to  render  things 
absurd.  Her  tone  is  careless,  almost  abandoned.  She  states — "I  am  Adam's 
first  daughter,  and  came  here  in  the  year  1 ;  came  here  because  my  mother  came 
first:  I  think  I  couldn't  give  you  more  straightforward  answers,  could  I?"  then 
lauglis  and  becomes  obscene  and  repulsive. 

As  on  the  former  occasion,  the  excitenvent  completely  abated  in  a  fortnight's 
time  from  admission;  but  only  to  return  again  in  a  violent  form,  marked  by  all 
tlie  features  above  depicted,  and  extending  over  a  period  of  about  two  months, 
when  a  gradual  improvement  succeeded,  until  complete  convalescence  was  ensured. 

Recurrence  at  the  Climacteric. — Here,  again,  we  recognise  the 
form  of  insanity  which  is  regarded  as  more  or  less  characteristic  at 
this  period  of  life ;  it  signifies  little  when  the  recurrent  seizures 
originated,  whether  during  adolescence,  later  adult  life,  or  at  the 
menopause,  the  symptoms  of  the  attack  existing  at  this  latter  period 
conform  to  those  with  which  we  are  familiar  at  this  revolutionary 
epoch.  Former  attacks  may  have  been  characterised  by  maniacal 
excitement — the  attack  at  the  climacteric  is  almost  certainly  one  of 
depression,  mental  unrest  and  gloom,  and  of  delusional  perversions  of 
the  melancholic  stamp.  Take  for  instance,  as  illustrative  of  this 
statement,  the  following  case  in  which  climacteric  insanity  eventually 
issued  in  senile  insanity  : — 

H.  0.,  aged  forty-eight,  married  ;  admitted  Ma}",  1S69.  Historj-  of  paternal  in- 
temperance— an  aunt  hung  herself — an  uncle  died  in  a  lunatic  asylum.  H.  0.  had 
been  intemperate,  but  had  enjoj-ed  good  health.  Of  three  children  borne  Viy  her, 
one  died  of  convulsions.  The  alleged  cause  of  her  present  attack  was  domestic 
anxiety,  embracing  supposed  infidelity  on  the  part  of  her  husband,  and  occurring 
at  the  period  of  the  climacteric.  Depression  of  mind,  lasting  some  six  months, 
culminated  in  an  attack  of  melancholia,  with  marked  delusions  of  suspicion,  from 
which  she  recovered  after  a  residence  of  ten  weeks. 

Was  re-admitted  after  the  lapse  of  thirteen  years.  Part  of  this  inter\-al  had 
been  spent  in  Wadsley,  and  she  had  been  discharged  but  one  week  when 
depression  of  spirits  and  apprehensive  fears  beset  her,  and  she  developed  the 
tlehision  that  chloroform  was  secretly  administered  to  her.  She  admitted  having 
been  addicted  for  years  to  alcohol  in  excess  ;  showed  great  defect  of  memory, 
witii  much  blunting  of  intellect  and  emotions.  Was  industrious  in  habits,  but 
heavy  and  sluggish  in  manner,  and  of  vacant  expression.  Recovered  four  months 
after  admission. 

Remaining  at  home  for  nineteen  months,  she  managed  to  perform  her  household 
duties  fairly,  and  though  never  quite  well,  was  orderly  and  manageable.  Gradually, 
she  developed  delusions  of  the  former  type — suspicion  of  intended  harm  and 
attempts  to  chloroform  her,  basing  these  on  tremulous  conditions  of  her  limbs,  and 
apparently  also  on  certain  anomalous  subjective  sensations,  perhaps  hallucinatory'. 


Till';    CLIMACTERIC    AND    SENILE    EPOCHS.  211 

There  was  some  pro^'rc.ss^vo  dementia  and  slu^gisliness  of  intellectual  operations, 
with  emotional  dulness  and,  especially,  defect  of  memory.  Xevcrtheless,  in  two 
months'  time  she  improved  sufficiently  to  justify  her  discharge.  Her  recovery 
only  lasted  a  couple  of  months,  though  she  abstained  from  alcohol ;  she  developed 
restlessness,  insomnia,  melancholic  fear.s,  and  delusions.  When  re-admitted  for 
the  fourth  time,  she  was  anxious  and  apprehensive,  but  not  burdened  with  sus- 
picion to  the  same  e.Ktent  as  before ;  complained  of  confused  feeling  in  her  head, 
was  inappreciative  and  highly  forgetful.  From  that  time  forth  she  was  often 
restless  and  unsettled,  fancying  that  her  relatives  were  about  the  building, 
experiencing  both  aural  hallucinations  and  visual  illusions,  and  showing  much 
mental  enfeeblement  and  ever-increasing  failure  of  memory.  There  was  much 
pallor  of  the  face,  the  skin  assumed  a  parchment-like  aspect,  and  the  larger 
vessels  began  to  evidence  atheromatous  change.  In  this  state  she  still  remains  an 
inmate  of  the  asylum. 

The  instances  of  recurrent  insanity,  recorded  in  eighty  women, 
took  their  origin  at  the  follovving  respective  ages  : — 

Up  to  23  yrs.— 30  yrs.— 10  yrs.— 50  yrs.— GO  yrs.— 70  yrs.    Doubtful.    Total. 
Number  of  recurrent  cases 

occurring,        ...      2  10         15         25         24  2  2  SO 

Number  in  which  first  at- 
taclc  occurred  at  each 
period,    ....     11         22         17        15  3         ...  12  80 

From  this  table  we  glean  the  fact  that  although  the  largest  pro- 
portion of  cases  of  recurrent  insanity  admitted  are  from  forty  to  sixty 
years  of  age,  yet  the  greater  number  of  recurrents  date  their  first 
attack  from  twenty  to  thirty  years  of  age ;  and  that  nearly  the  same 
proportion  of  first  attacks  occur  from  thirty  to  fifty  years,  as  for  all 
periods  below  thirty.  The  large  accumulation  of  cases,  therefore, 
which  appears  from  forty  to  sixty  years  of  age,  is  due  not  to  the 
greater  tendency  to  the  origination  of  this  form  of  insanity  at  this 
epoch  of  life — in  fact,  we  see  the  tendency  decline  towards  fifty — but 
to  the  addition  of  patients  who  have  already  had  attacks  in  earlier  life. 
Hence,  we  must  conclude  that  this  epoch  of  life  has  no  special 
influence  in  originating  this  form  of  insanity ;  but  that  it  is  especially 
prone  to  excite  its  recurrence  in  those  who  have  already  sufi"ered 
therefrom. 

Recurrence  at  the  Senile  Epoch. — The  same  reasoning  applies 
to  the  later  epoch  of  senility.  Reverting  to  the  same  table,  it  is 
evident  that  although  as  many  as  twenty-four  cases  of  recui-rent 
insanity  were  admitted  between  the  ages  of  fifty  and  sixty  years,  the 
great  bulk  were  but  relics  of  former  storms,  since  three  out  of  the 
number  only  appear  to  have  had  their  first  attack  of  insanity  in  this, 
the  sixth  decade  of  life. 

J.  S.,  aged  sixty,  married;  admitted  April,  1S74.  Patient  belonged  to  a  highly 
neurotic  stock.     Her  mother  and  sister  were  both  iusauc;   her  brother  cut  his 


212  PERSISTENT    MENTAL    INSTABILITY. 

throat;  ami,  at  a  subsequent  period,  her  sister's  son,  hecominc;  the  subject  of 
impulsive  insanity,  murdered  liis  mother  in  tlie  most  Ijrutal  manner,  kicking;  her 
to  death,  and  causing  the  most  terrible  mutilations  of  her  head  and  body.  Her 
symptoms  had  shown  a  long  ])rcmonitory  stage ;  but  four  months  prior  to  admis- 
sion, she  was  restless,  garrulous,  betrayed  alternations  of  despondency  and  excit- 
ability, with  suspicious  tendencies.  When  she  came  under  observation,  she  was 
low-spirited,  possessed  of  ill-defined  apprehensions  of  evil,  and  betrayed  painful 
emotion  over  trivialities,  totally  inadetjuate  to  jirovoke  such  distress  in  a  normal 
state.  She  had  a  sharp,  weazened  aspect,  with  dark  piercing;  eyes;  was  emaciated 
and  shrunken.  A  decided  liypochondriacal  element  was  indicated  by  the  promin- 
ence assigned  to  imaginary  ailments  and  a  craving  for  sympathy.  She  would  talk 
for  hours  about  her  ailments,  and  was  most  importunate  upon  such  subjects  at  all 
times.  Incessantly  restless,  she,  at  times,  proved  most  im])ulsive;  her  uncon- 
trollable feelings  being  embodied  by  her  in  an  imaginary  ailment,  "  itch  in  the 
blood,"  to  which  she  declared  she  was  subject.  At  her  worst  moments,  she  would 
fly  passionately  at  other  patients  without  any  provocation,  endeavouring  to  inflict 
injury  upon  them,  and  subsequently,  evince  a  hypocritical  penitence,  and  queru- 
lously dwell  upon  her  ailments  ;  at  other  times,  her  impulsiveness  tended  to 
suicidal  acts.  Being  discharged,  "relieved,"  to  her  husband's  care,  she  subse- 
quently relapsed,  and  then  attempted  hanging  herself  in  a  wardrobe ;  but,  being 
detected,  rushed  to  the  window  with  intent  to  leap  from  it.  She  was  readmitted, 
and  remained  at  the  asylum  fretful,  self-engrossed,  importunate,  and  impulsive  in 
conduct  to  her  death  at  the  age  of  seventy-two. 

All  our  evidence,  therefore,  points  to  the  late  adoleSCent  and 
early  adult  life  as  the  period  peculiarly  prone  to  this  form  of 
nervous  disease;  nor  need  we  be  surprised  at  the  fact,  for  at  this 
period  we  meet  with  important  revolutionary  changes  in  the  economy, 
the  tendency  to  the  fostering  of  morbid  excitement,  and  alcoholic 
indulgence :  at  a  period  when  in  the  struggle  for  existence  the  demands 
for  a  more  refined,  delicate,  and  complex  adaptation  are  imperativel}' 
made  upon  the  organism,  and  tell  with  especial  effect,  therefore,  on 
the  central  co-ordinating  nervous  system.  Given  these  as  the  in- 
fluences operating  in  the  development  of  the  parental  form,  the  law 
of  "limitation  by  ag'e"  will  apply  as  explanatory  of  its  reappearance 
at  the  same  period  in  the  offspring. 

Recurrence   in    Puerperal    Cases. — A  certain   proportion   of 

women  betray  a  tendency  to  maniacal  perversions  upon  the  accom- 
plishment of  each  parturition,  or  during  the  early  days  of  each 
puerperum.  These  are  subjects  whose  heritage  is  probably  identical 
with  those  already  considered.  In  no  particular  does  the  seizure 
differ  from  what  we  know  of  ordinary  puerperal  mania,  other  than  in 
this  simple  tendency  to  recur. 

M.  B.,  aged  twenty-eight,  married ;  admitted  February,  1S79.  History  of  pater- 
nal intemperance — a  sister  melancholic,  but  did  not  require  asylum  treatment.  The 
patient,  after  her  fourth  confinement,  a  severe  one,  in  1876,  developed  symptoms  of 
insanity,  and  was  removed  to  Wadsley,  where  she  was  retained  about  two  months. 


PUERPERAL   AND   TRAUMATIC   CASES.  213 

Four  months  prior  to  her  admission  at  Wakefield,  her  fifth  confinement  occurred, 
after  which  she  became  depressed,  distrustful  of  her  husband,  and  manifested 
distaste  towards  her  infant;  finally,  threatened  to  commit  suicide  and  cut  the 
throats  of  her  husband  and  family.  When  received  into  the  asylum,  she  was  con- 
valescing from  mania  and  rapidly  became  quiet,  industrious,  and  fairly  cheerful. 
There  was  neither  continuance  of,  nor  return  to,  the  homicidal  tendency  ;  she 
was  sent  out  recovered  in  less  than  two  months.  The  interval  between  the  pre- 
ceding and  the  following  attack  was  five  years,  during  which  time  patient  had 
two  children ;  the  last  labour  being  followed  by  post-parlum  haemorrhage  and, 
more  remotely,  by  profuse  menstruation.  It  appeared  that  she  soon  showed 
mental  aberration  after  her  discharge,  developing  suspicious  ideas  about  her  neigh- 
bours, and  fancying  that  they  jeered  at  her  and  called  her  names,  and  it  was 
stated  that  she  attempted  to  cut  her  child's  throat.  On  re-admission,  there  was 
much  intellectual  and  emotional  torpor,  gloom  and  apprehensiveness  of  evil,  and 
for  some  time  much  querulous  and  fretful  behaviour,  anxiety,  and  hypochondriacal 
fancies,  which,  at  times,  were  exaggerated  into  actual  delusions  of  suspicion  ; 
after  a  period  of  four  months  she  gradually  became  more  cheerful  and  composed, 
and  one  month  later  was  fitted  for  discharge. 

Recurrence  in  Traumatic    Cases.— It  is  a  fact  of  no  small 

import,  that  20  per  cent,  of  the  male  recurrents  had  suffered  from 
cranial  injury,  usually  due  to  falls  from  a  height  \ipon  the  head,  or 
to  a  violent  blow  causing  teraporaiy  unconsciousness.  The  injury  in 
no  case  amounted  to  fracture,  or  depression  of  bone,  but  was  probably 
confined  to  molecular  disturbance  and  nutritive  anomalies  thereby 
established.  The  following  case  is  an  instance  of  insanity  engendered 
in  an  individual  of  the  criminal  type,  wherein  cranial  injury  and 
alcohol  were  important  factors  in  the  causation  : — 

B.  L.,  aged  twenty-seven,  married,  hawker;  transferred  from  gaol,  December, 
1883.  The  only  information  as  to  the  family  history  of  this  patient  was  obtainable 
from  the  latter  herself,  who  stated  that  her  father  had  been  an  excessive  drinker, 
and  her  sister  an  inmate  of  the  W.  R.  Asylum. 

She  was  committed  to  twelve  months'  hard  labour  for  assaulting  and  wounding 
a  woman  whom  she  believed  to  cohabit  with  her  husband.  This  belief,  as  well  as 
the  alleged  cruelty  towards  her  of  the  latter,  appeared  to  be  actual  facts,  which, 
added  to  long  and  excessive  indulgence  in  alcoholic  stimulants,  had  produced  her 
l)resent  mental  disorder.  Her  forehead  was  deeply  scarred,  as  the  result  of 
injuries  received  by  a  fall  upon  the  head  some  years  previously. 

Whilst  in  prison,  the  patient  behaved  with  great  violence  to  her  fellow- 
prisoners  and  the  warders,  and,  on  one  occasion,  made  a  desperate  attempt  at 
suicide,  being  discovered  in  her  cell,  black  in  the  face  from  strangulation,  eft'ected 
by  a  piece  of  cord  tied  round  the  neck.  During  this  time,  also,  she  maintained  an 
obstinate  silence.  She  spoke  on  removal  to  the  asylum,  explaining  that  God  had 
enjoined  her  to  be  dumb  while  she  was  in  hell— /.e.,  prison.  At  first  abstracted 
and  suspicious,  exhibiting  many  purposeless  tricks  of  gesture  and  countenance,  she 
quickly  became  an  active  and  industrious  inmate,  showing,  however,  some  irra- 
tionality, together  with  considerable  want  of  control.  Although  no  delusions  of 
suspicion  regarding  those  surrounding  her  were  manifest,  yet  the  low  type  of  her 


214  •    PKHSISTKNT    MKNTAF.    INSTAI5IMTY. 

■a]H)carance  received  coiifiimation  in  occasioual  outbursts  of  violence,  witliout 
adequate  cause,  and  at  all  times  characterised  by  the  utmost  Ijrutality.  Her 
behaviour,  however,  not  deserving  of  the  license  of  insanity,  siie  was,  after  a  resi- 
dence of  three  months,  sent  Ijack  to  gaol. 

In  less  tlian  two  months  she  had  another  outbreak,  and  became  most  violent, 
abusive,  and  foul-mouthed  ;  procuring  a  medicine  bottle  belonging  to  another 
prisoner  she,  with  the  intention  of  suicide,  drank  half  its  contents  before  she 
could  be  prevented.  She  was,  on  her  return  to  the  asylum,  most  maniacal, 
aggressive,  obscene,  and  apparently  the  subject  of  hallucinations.  In  this  state 
she  remained  for  nearly  a  week,  when  she  commenced  gradually  to  improve, 
and  ultimately  settled  down  into  a  quiet  affable  patient  of  industrious  habits,  witii 
the  exception  of  two  or  three  passionate  outbursts  of  short  duration.  Apart  from 
actual  insanity,  nevertheless,  she  could  only  be  regarded  as  of  low  and  degraded 
nature.  Discharged  within  a  month  of  the  expiration  of  her  sentence,  "  relieved." 
Since  her  discharge  she  has  frequently  figured  in  the  police  courts;  has  been 
several  times  in  prison,  and,  during  her  imprisonment,  her  conduct  has  been 
characterised  by  the  utmost  brutality,  ferocious  violence,  and  vindictiveness. 

Frequency  of  Morbid  Impulse.— ^ome  31  per  cent,  of  tlie  13G 

instances  of  i-ecurrent  insanity  manifested  suicidal  tendencies,  Ijotli 
sexes  being  about  equally  subject  to  sucli  promptings.  The  melancholic 
forms,  and  the  maniacal  outbursts  associated  with  depressing  delusions, 
were  especially  prone  to  such  impulses;  thus,  six  cases  alone  show 
this  tendency  in  women  below  the  age  of  forty  years,  all  the  remaining 
suicidal  cases  being  at  the  climacteric  period. 

In  the  male,  on  the  other  hand,  this  morbid  tendency  comes  out 
strongly  in  the  younger  members;  but  in  all  these  instances  the  form 
of  insanity  was  that  characteristic  of  alcoholic  and  masturbatic 
excesses,  and  delusions  of  persecution  prevailed  in  each.  Even  in  tlie 
few  cases  occurring  below  forty  years  of  age  in  the  female,  the  self- 
destructive  impulse  appeared  based  upon  congenital  instability  or 
alcoholic  indulgence. 

Dangerous  aggressive  conduct  prevailed  in  over  52  per  cent,  of 
female  recurrents,  and  in  64  per  cent,  of  the  males,  or  an  average  for 
both  sexes  of  57  per  cent. 

Hence,  recui-rent  insanity  embraces  a  very  high  ])roportion  of  in- 
dividuals dangerous  to  others — a  fact  exi)hiined,  in  like  manner,  by 
the  large  number  addicted  to  vicious  habits  of  life,  and  especially 
alcoholic  excess.  With  respect  to  this  morbid  impulsiveness,  Dr. 
Sankey,  reaffirming  witli  M.  Morel  its  i-csemblance  to  epilepsy, 
writes  : — "  There  is  the  same  periodicity  in  the  cases,  the  same  im- 
pulsiveness, and  the  same  ignorance  or  blindness  of  their  own 
position ;  and  though  the  acts  of  violence  are  not  attended  witli 
any  unconsciousness,  yet  they  seem  scarcely  voluntary."  *     Amongst 

*  Op.  ci(.,  p.  175. 


THE    CRIMINAL    INSANE  :    HALLUCINATIONS    AND    DELUSIONS.     '■    21~} 

this  class  are  comprised  many  of  the  criminal  community  of  low 
mental  type,  often  associated  witli  a  degraded  physical  conformation. 
These  patients  are  almost  all  confirmed  drunkards ;  spend  the  greater 
part  of  their  life  between  the  prison  and  the  asylum;  and,  in  the 
former,  often  sham  insanity  with  the  object  of  attaining  tlieir  removal 
to  an  asylum.  Here,  if  not  repressed,  they  would  become  the  tyrants 
of  the  community  amongst  whom  they  live ;  and,  in  their  maniacal 
attacks,  are  most  dangerously  impulsive,  reckless  of  life  or  limb  ;  their 
conduct  often  i^rompted  by  the  utmost  brutality  and  the  most  vicious 
instincts.  Beyond  the  trouble  given  by  the  criminal  class  in  an  institu- 
tion where  severe  repressive  measures  are  to  be  discouraged,  they  form 
a  scourge  to  the  younger  and  more  respectable  class  of  patients  whose 
malady  is  their  misfortune,  and  whose  former  associations  were  far 
different.  This  social  evil  is  a  blot  upon  our  legislature  that  loudly 
calls  for  redress. 

Hallucinations    and    Delusions.— Hallucinations    prevailed    in 
22-7  per  cent,  of  the  recurrent  cases— the  visual  and  aural  in  about 
the  same  proportion,  and  both  associated  in  a  few  cases;    olfactory 
hallucinations   or  illusions  were  seldom    noted,   and   gustatory  were 
notably  absent.    Delusions  occur  in  at  least  half  the  cases  (53  per  cent.) 
Both  hallucinatory  and  delusional  states   vary  with    the   proximate 
cause   of  the   outbreak :    if  alcoholic  excess   enters    largely  into    the 
causation,  we  may  anticipate  associated  ideas  of  self-importance,  rank, 
power,    wealth,    and   suspicion    of   perfidy   upon    the    part    of   those 
around  him.     One  patient  receives  a  nightly  visit  from  his   satanic 
majesty;    another  sees  imps   around   him,   hears   voices  beneath   the 
floor — the  noise  and  rumble  of  machinery,  which  his  morbid  imagina- 
tion frames   into    some   idea   of  coming   torture.      Another   patient, 
twentj^-eight  years   of  age,   addicted  to  intemperance  in   drink,   and 
the  subject   of  a  serious  cranial  injury  in  youth,   calls    himself  Sir 
Eoger  Tichborne,  and  accuses  his  relatives  of  filling  his  bedroom  with 
the   vapour    of  chloroform.      Another  young  alcoholic   subject   owns 
property   "to    the    value    of  thousands    a   year"— has    extraordinary 
muscular  power,   and   can  "walk   eighty  miles   a   day  continuously." 
Delusions   of  poisoning  are  frequent  in  these  alcoholic  cases,  as  are 
also  notions  of  being  deprived  of  property  and  rights,  or  being  pur- 
sued by  the  messengers  of  the  law.     One  typical  case,  aged  thirty-eight 
years,  with  a  history  of  paternal  intemperance  and  strong  collateral 
insanity  (two  sisters  being  insane),  himself  for  years  a  heavy  drinker, 
developed,  upon  his  third  outbreak  of  insanity,  the  notion  (from  certain 
subjective  feelings  referred  to  the  chest)  that  some  mysterious  clock- 
work was  concealed  there,  which  caused  him  much  agony  and  deranged 
his   mind.      He   could  scarcely  be   restrained  from  injuring    himself, 


216  PERSISTENT    MENTAL    INSTADILITY. 

and  often  begged  to  be  operated  upon  witli  a  view  to  its  removal. 
He  frequently  bruised  himself  seriously  over  the  front  of  the  chest 
by  violent  blows  of  the  closed  fist. 

J.  B.,  aged  thirty-six,  married,  a  fish-hawker,  admitted  August,  1S82.  Has  had 
no  previous  attack  of  insanity.  Eight  days  previously  he  became  maniacal  and 
dangerously  aggressive ;  was  under  the  constant  charge  of  two  men  at  the  work- 
house, whitlier  he  had  been  taken.  There  he  attempted  to  leap  from  a  window, 
and  struck  his  forehead  with  a  soda-water  bottle,  inflicting  a  severe  gash,  with 
suicidal  intent.  U])on  admission  he  was  depressed,  heavy,  and  sluggish,  yet 
sufiBciently  calm  to  give  a  clear  account  of  himself.  His  height  was  ii  feet  5  inches  ; 
his  weight  124  lbs. ;  he  was  ill  nourished,  with  flabby  muscles  ;  complexion  sallow 
and  dirty  ;  several  deeply-incised  wounds  recently  inflicted  were  observed  on  fore- 
head ;  expression  depressed  and  torpid.  The  tongue  was  not  foul,  no  anorexia, 
and  no  functional  derangement  of  the  several  viscera  present.  Patient  gave  a 
history  of  excessive  drinking  for  some  years  past,  as  also  of  an  attack  of  delirium 
tremens;  had  been  drinking  quite  recently,  and  "saw  all  sorts  of  things  about 
him."  Two  sisters  were  insane,  but  all  other  antecedents  free  from  neuroses  ;  his 
father  was  a  heavy  drinker.  He  admitted  being  jealous  of  his  wife,  whose  fidelity 
he  questioned,  and  he  had  therefore  deserted  her  and  his  children.  During 
the  first  week  he  remained  morbidly  depressed,  pensive,  self-absorbed,  and  in- 
active;  rarely  spoke,  but  said  he  was  quite  "beside  himself"  when  he  cut 
his  forehead;  appetite  good;  "nasty  foul  objects"  surround  him;  was  gloomy. 
A  week  later  no  further  illusory  or  hallucinatory  state  prevailed  ;  appeared  of  nor- 
mal consciousness,  and  was  shortly  afterwards  employed  for  a  time  at  work,  and 
discharged. 

The  next  occasion  upon  which  we  hear  of  him  was  in  December,  18S4,  about  two 
years  following  his  discharge.  During  the  interval  he  had  gone  to  America, 
resumed  his  drinking  habits,  and  was  soon  an  inmate  of  the  Trenton  Asylum. 
When  re-admitted  here,  he  had  developed  typical  delusional  notions;  declared  that 
some  clockwork  machinery  was  within  his  chest — the  movements  were  incessant, 
caused  him  great  suffering,  and  allowed  him  no  rest ;  felt  impelled  to  commit 
suicide.  The  voice  of  a  man  also  was  heard  speaking  to  him  from  within  his 
body.  He  was  irritable,  violent,  dangerously  suicidal,  and  his  language  abusive 
and  blasphemous.  He  describes  the  "clock"  in  his  chest  as  causing  sensations 
like  "a  chopping  machine  ;"  it  feels  as  if  it  would  "rive  his  heart  out:"  begs  to 
have  a  surgical  operation  performed  iijion  his  chest,  that  "the  machinery  may  be 
cut  out ;"  and  he  points  to  several  recent  bruises  over  the  manubrium  inflicted  by 
his  clenched  fist  to  relieve  the  anguish  he  feels.  Believes  certain  men  have  placed 
the  "  clockwork"  there  to  make  him  jump  and  dance  about  whenever  they  choose. 
He  became  much  agitated  and  excited  during  this  narration  ;  talked  hurriedly  and 
incoherently.  He  had  increased  in  weight ;  his  tongue  was  clean  and  steady  ; 
there  were  notwitchings  of  facial  muscles  or  labial  tremor  ;  articulation  was  unim- 
paired ;  pupils  were  normal  in  size  and  reaction  ;  bodily  functions  all  well 
performed. 

For  two  months  he  continued  to  exhibit  the  symptoms  above  described,  was 
alwaj's  excitable,  s])oke  in  a  hurried  flow  of  words,  but  was  coherent ;  he  proved 
friendly  in  his  di.'^position  to  those  around  him,  took  much  interest  in  his  domestic 
employments,  and  was  fairly  cheerful. 

Mt/i  February,    1885. — A  relapse  occurred  at  this  date  ;  the  delusion  became 


ALCOHOLIC    RECURRENTS  :    PROGNOSIS.  217 

again  more  prominent,  and  he  repeatedly  threatened  to  cut  his  throat.  For  the 
subjective  anomalies  leeches  were  applied  to  the  manubrium,  but  without  result. 
Bromide  and  chloral  were  then  given  with  very  considerable  benefit ;  the  pain 
gradually  subsided ;  his  sleep  was  ensured  at  night ;  and  by  tlie  30th  of  March  he 
declared  himself  free  from  any  morbid  sensations,  had  lost  his  delusional  notions, 
was  quite  rational  in  converse,  and  left  the  asj'lum. 

In  one  month  later  he  again  became  an  inmate,  suffering  from  his  fourth  attack 
of  mania-a-potu.  His  delusional  state  was  similar  in  nature  to  that  above  noted. 
The  "clockwork"  still  drives  him  frantic;  he  must  cut  open  his  own  chest 
and  remove  it,  or  will  "split  open  the  chest  of  some  ooe  else  ;"  he  will  "murder 
those  who  persecute  him."  Says  he  went  home,  worked  steadily,  and  remained 
quite  well,  abstaining  from  drink  for  two  weeks,  and  then  the  terrible  feehngs  in 
his  chest  began  again,  causing  sharp  lancinating  pains,  which  had  "  the  power  of 
arresting  his  breathing,  and  caused  agony  even  to  his  finger-tips."  He  strikes 
himself  violently  upon  the  chest  in  sheer  despair,  and  is  much  bruised  over  the 
sternum.  Threatens  to  take  his  own  life  unless  relieved  by  some  operation  ;  is 
very  excitable,  garrulous,  circumlocutory,  irate.  He  took  liquor  opii  with  sjiiritus 
aitheris  sulph.  (aa  mins.  xv.)  twice  daily.  During  the  first  fortnight  he  derived 
relief  from  the  opiate,  but  continued  to  exhibit  mild  maniacal  excitement ;  was 
very  garrulous,  easily  upset,  and  became  passionate  when  talking  of  his  morbid 
sensations.  He  remained  very  deluded,  and  about  this  time,  having  secured  a 
knife,  he  retired  to  a. closet,  and  inflicted  a  deep  incised  wound  down  the  front  of 
the  chest  over  the  sternum  ere  he  was  detected.  Chloral  and  bromide  (aa  grs.  xxx. ) 
were  substituted  for  the  opiate  twice  daily ;  steady  improvement  took  place — he 
lost  his  painful  sensations,  but  upon  retrospect  he  still  affirmed  the  reality  of  the 
diabolical  machinery  which  had  been  introduced  into  his  chest.  A  few  weeks 
later  he  was  finally  discharged  as  recovered. 

PPOg'nOSiS. — A  large  pi'oportion  of  the  recurrent  insane  who  enter 
our  asylums  after  successive  attacks  of  insanity  become  chronic  inmates, 
or  are  discharged  as  partial  cures  only,  or  the  disease  proves  fatal. 
Considerable  disparity,  however,  appeal's  to  be  maintained  between  the 
rate  of  recovery  amongst  the  male  and  the  female  residents;  the  former 
range  as  high  as  714  per  cent,  of  the  total  number,  the  latter  57*5 
per  cent.  If  we  group  together  as  "  unfavourable  cases "  all  partial 
recoveries,  deaths,  and  chronic  remnants  of  the  recurrent  female  class, 
we  find  these  amount  to  40  out  of  a  total  of  100  cases. 

We  find  that  of  the  "relieved,"  the  deaths,  and  the  "remaining," 
only  10  cases  of  the  40  wex'e  under  forty  years  of  age,  the  melancholic 
form  which  prevails  beyond  this  age  being  a  far  less  recoverable  form 
of  insanity  than  the  acute  excitement  of  earlier  life.  One  most 
unfavourable  aspect  of  recurrent  insanity,  therefore,  is  that  of  a 
recurrence  at  the  period  of  forty  and  upwards ;  in  fact,  if  we  fail  to 
break  through  the  periodicity  established  in  our  patients'  morbid 
tendencies,  before  this  age,  the  outlook  is  very  ominous — the  lucid 
intervals  between  their  attacks  become  of  shorter  duration,  and  the 
mental  stability  at  their  best  moments  so  insecure,  that  in  impulsive 
forms  it  becomes  imperative  to  keep  them  under  continuous  super- 


218  PEnSISTKNT    MENTAL    INSTAI5ILITV. 

vision.  The  period  of  calm  between  the  attacks  is  not  only  more 
uncertain  in  its  duration,  but  there  is  now  betrayed  a  steadily 
advancing  mental  enfeeblement ;  and,  as  dementia  deepens,  so  do  the 
attacks  of  excitement  or  depression  become  more  frequent  and  more 
prolonged ;  yet,  even  in  these  advanced  cases,  the  periodicity  of  the 
disease  is  maintained.  Dr.  Blaudford  cites  the  case  of  a  man  of  more 
than  eighty  years  of  age,  who  came  under  his  observation,  whose 
first  attack  happened  wlien  lie  was  seventeen,  and  who  had  Vjeen 
placed  under  supervision  for  recurrent  attacks  three-and-thirty  times.* 
A  patient  at  the  "West  Hiding  Asylum  between  the  age  of  thirty-two 
and  forty-two  had  an  attack  almost  every  year,  nine  in  fact ;  between 
each  of  which  she  was  dischai'ged,  and  resumed  her  household  duties 
with  energy  and  ability,  manifesting  no  intellectual  impairment  or 
emotional  instability. 

In  another  case— a  mai'ried  woman,  addicted  to  heavy  drinking, 
had  her  first  attack  at  the  age  of  thirtj'-five,  and  from  this  period 
through  the  whole  of  the  climacteric,  was  subject  to  repeated  attacks 
of  maniacal  excitement  of  a  wild,  boisterous,  and  dangerous  nature, 
with  obscene  and  most  objectionable  behaviour.  In  her  case,  asylum 
supervision  was  required  on  ten  occasions  up  to  the  age  of  sixty  years  ; 
but,  for  several  other  attacks  of  excitement,  she  was  treated  at  home 
and  recovered. 

In  yet  another  instance,  a  young  girl  of  congenitally  weak  moral 
control  sutfered  from  three  successive  attacks,  with  complete  lucid 
intervals,  between  the  ages  of  seventeen  and  nineteen ;  she  returned 
home  and  resumed  her  duties  in  the  intervals  of  her  attacks.  Three 
further  attacks  occurred  up  to  the  age  of  twenty -four  years,  when  her 
mental  equilibrium  was  so  far  unsteadied  that  she  continues,  up  to  the 
present  time  (a  pei'iod  of  two  years),  an  inmate  of  our  wards.  During 
this  latter  residence  she  has  had  repeated  attacks  of  excitement,  and 
her  periods  of  calm  are  now  greatly  broken  by  hysteric  symptoms,  in 
which  erotic  manifestations  are  prominent.  In  her  case,  also,  diurnal 
calm  often  alternates  with  nocturnal  restlessness,  gentle  excitement, 
and  garrulity. 

"The  disorder,  once  set  up  in  the  individuars  constitution,  is  prone  to  recur, 
and  we  must  examine  the  whole  question  of  the  periodicity  of  disease,  as  well  as 
the  conditions  of  the  first  attack,  before  we  can  hope  to  throw  any  light  upon  the 
subject.  This  much  we  may  conclude,  that  the  conditions  which  precede  the  first 
are  not  necessary  to  subsequent  attacks;  that  as  epileptic  seizures  may  continue 
after  the  ostensible  cause  of  the  first  fit  is  removed — e.rf.,  worms,  so  the  disorder 
once  recurrmg  may  repeat  itself,  persistently  remaining  as  a  vice  of  the  constitu- 
tion of  the  individual,  of  which  it  now  forms  a  portion  "  {Bla7id/ord)f. 

*  Insanity  and  its  Treatment,  p.  "1.  +  Oj).  cit.,  p.  72. 


PROGNOSIS    IN    HIX'UimENT    INSANITV.  *2l9 

"Witli  this  statement  of  Dr.  Blaiidfoi'd  we  fully  agi-oe,  so  long  as  it 
is  inulerstood  that  the  conditions  of  the  first  attack,  to  whicli  he. 
alludes,  are  environincj,  and  not  organised,  conditions ;  for  it  is  all- 
important  to  bear  in  mind  that  a  very  large  proportion  of  the  cases 
exhibit  a  powerful  hereditary  predisposition  to  insanity,  and  that  we 
always  ftiil  to  elicit  to  the  full  extent  from  the  most  careful  enquiries 
the  magnitude  and  importance  of  inherited  neurotic  conditions.  Yet 
out  of  the  136  persons  who  were  subject  to  recurrent  seizures,  permitting 
them  to  return  to  their  homes  in  the  intervals  of  their  attacks,  we 
found  very  definite  and  undoubted  evidence  of  inherited  insanity,  of 
other  neuroses,  or  a  history  of  parental  intemperance,  or  of  severe 
cranial  injury  in  seventy  individuals  (51-4  per  cent.)  If,  therefore,  in 
one-half  tYie  cases  such  powerful  predisposing  factors  be  found,  any  one 
familiar  with  statistical  research  in  this  direction  will  add  a  wide 
margin  for  similar  agencies  in  other  cases  not  divulged,  too  remote  for 
detection,  or  in  patients  whose  antecedents  are  utterly  unknown,  as  so 
often  occurs  in  the  class  with  which  we  deal  at  large  pauper  institu- 
tions. If  we  now  group  together  promiscuously  all  the  recurrent 
individuals  of  our  past  ten  years'  expei'ience  at  the  West  Riding 
Asylum,  we  may  construct  from  their  histories  a  chart  of  recoveries, 
such  as  is  given  on  Plate  6". 

A  steady  increase  occurs  in  the  number  of  recoveries  up  to  the  sixth 
month,  when  a  climax  is  reached — fifty -four  of  the  total  105  cases  of 
recovery  (or  167  total  cases  under  treatment)  having  been  discharged. 
One-half  the  recoverable  cases,  therefore,  are  well  by  the  sixth  month  ; 
a  notable  fall  occurs  between  the  seventh  and  eighth  months,  with 
a  slight  rise  of  seven  cases  at  the  ninth  month,  again  to  decline  to  the 
level  of  one  or  two  cases  monthly  until  the  thirteenth  month,  after 
which  the  recoveries  are  few  and  distant— (?.(/.,  one  at  twenty  months, 
one  at  two  years,  and  one  at  six  years. 

The  recovery  line  for  the  men  diflTers  from  that  of  the  women  in 
attaining  the  climax  two  months  later ;  the  largest  proportion  of  cures 
for  female  recurrents  (seventeen)  ta,king  place  during  the  fourth  month 
of  their  attack,  and  steadily  declining  to  the  seventh ;  whilst  the 
maximum  of  male  recoveries  (twenty -six)  occui's  at  the  sixth  month, 
dropping  suddenly  to  one  case  for  the  seventh  and  eighth  months.  Of 
the  females,  whose  recovery  was  protracted  beyond  the  ninth  month, 
all  without  exception  were  above  forty  years  of  age,  had  suffered  from 
several  previous  attacks,  or  were  subjects  of  congenital  mental  defect. 

Treatment. — When  considering  the  etiology  of  recurrent  forms  of 
insanity,  we  emphasised  the  hereditariness  of  the  affection,  and  the 
unstable,  defective,  mental  organisation  of  the  subject.  We  regard  the 
indulgence  in  alcoholic  stimulants  as  having,  perhaps,  a  more  fatal  effect 


220  PERSISTENT    MENTAL    INSTABILITY. 

upon  the  subjects  of  this,  than  of  those  of  any  other  form  of  insanity. 
Alcoholic  treiitment  here  is  decidedly  most  pernicious.  In  fact,  all 
forms  of  the  explosive  neuroses  do  better  without  any  alcohol — even 
when  their  disease  does  not  appear  to  have  been  engendered  by  undue 
indulgence  in  stimulants.  We  often  tind  that  the  subject  craves  for 
alcohol,  and  also  for  all  sorts  of  mental  excitation ;  but  these  must  be 
withheld  wherever  they  tend  to  induce  the  least  emotional  instability. 
Our  sheet-anchor  in  the  treatment  of  these  affections  is  much  outdoor 
exercise,  with  active  manual  employment  for  both  sexes,  long  walks, 
cheerful  society,  and  avoidance  of  association  with  the  more  excitable 
chronic  lunatics.  With  this  there  should  be  given  a  liberal,  whole- 
some dietary.  By  some  authorities  it  has  been  considered  well  to 
limit  the  meat-diet,  and  to  add  largely  to  the  farinaceous  and  vege- 
table constituents  of  the  food — a  suggestion  which  applies  also  to  the 
epileptic  and  other  convulsive  neuroses.  We  do  not  ourselves  regard 
the  question  of  the  advisability  of  a  farinaceous  diet  as  conclusively 
proved  in  the  case  of  the  convulsive  neuroses ;  the  most  important 
attempt  to  practically  test  the  question  in  epilepsy,  was  recorded  by 
Dr.  Merson,  in  the  "  West  Riding  Asylum  Medical  Repoi'ts  for  1875," 
the  result  being  in  the  main  favourable  to  this  dietary,  but  based  upon 
too  limited  a  number  of  instances  to  warrant  final  acceptance. 

Bromide  of  potassium,  in  combination  with  Indian  hemp  (30  grains 
of  the  former  to  a  fluid  drachm  of  the  tincture),  is  the  best  remedy  for 
the  states  of  acute  excitement.  The  patient's  appetite  is  never  pre- 
judicially aflfected  by  it.  In  most  cases  of  this  class  they  take  food 
more  readily  with,  than  without,  this  treatment. 

The  exaltation  of  the  sexual  instincts,  which  so  often  characterises 
these  recurrent  seizures,  renders  iron  and  the  compound  phosphates  inad- 
missible in  many  cases.  In  most  adolescents  the  recurrent  attacks  are 
best  met  by  bromides  alone,  careful  attention  to  the  bowels,  regular 
exercise,  the  spinal  douche,  followed  by  friction  of  the  surface;  and,  if 
there  be  much  insomnia,  an  occasional  chloral  draught. 

The  phosphatic  preparations,  with  cod-liver  oil,  may,  however,  be 
given  with  benefit  in  the  recurrent  attacks  of  melancholia  incident  to 
the  climacteric,  and  the  bromide  of  potassium,  in  combination  with  the 
perchloride  of  iron  is  often  advantageously  ])rescribed. 


Chart  A 


CH 

INSAN 

ART   of    RECOVERIES, 

ITY     AT     THE      CLIMACTERIC. 

Number  of   7 

Cases 

\\ 

l\ 

/ 

A 

j\ 

7 

A 

/ 

/  \ 

/ 

V 

A 

/ 

v. 

Duration  pr  Attack 

4» 

6,v. 

2m. 

5 

4 

5 

6 

7 

8 

9 

10 

II 

12 

ij 

1+ 

15 

16 

19 

20 

2y  4y 

,,     ,      r  CHART |of  RECOVERIES  in  RECURRENT  FORMS  of  INSANITY. (167  Cases.) 


Cases,    10 

% 

\ 

• 

/ 

A 

\ 

1 

/\ 

/ 

\ 

J 

A 

/\ 

v' 

\ 

'/ 

/ 

V 

X 

'"{ 

\ 

n\ 

/■^ 

\ 

■'" 

V 

\ 

Duration  of  Attack 
up  to 

,... 

6.1 

2« 

i 

4 

5 

e 

7 

8 

9 

10 

II 

12 

15 

14- 

15 

18 

2/ 

3/ 

5/ 

Note-  Black J.inc   MALE    Jtecitmnbi    67  Caa, 
FEMALE  .  700       . 


ANALYSIS   OF    RESULTS. 

Recovered       RelievetJ        Died         Chronic 
Male        4-6  1+3  4. 

Female     5  9  15  8  18 


221 


EPILEPTIC  INSANITY. 

Contents:  — Pefiiiition  —  Eiiileiitic  Neurosis  — Immediate  and  Eemote  Kesults  of 
Epileptic    Discharge  —  Diffusiou-curreuts  --  Nascent   Nerve-tracts  —  iJiscliarKc 
from  Sensory  Areas— The  Aura  in  Sensory  Epilepsies— Epileptic  Amaurosis, 
Hemianopsia    and    Hemiansesthesia— Ciiaiiii)ing    Movements— Pre-paroxysmal 
Stage— Premonitory  Sta^e — Special   Sense  Aurae-Vaso  motor  and  Visceral 
Aur:e— The    Epileptic    Paroxysm —  Grand  and    Petit  Mai— Post-jiaroxysmal 
Period— Post-epileptic  Automatism  — Case  of  E.  C— Status  Epilepticus- Inter- 
paroxysmal  Stage— Epileptic  Hypochondriasis,  Automatism  and  Impulsiveness 
—  Medico-legal  Relationships — Impulse— Delusion --Malingering— Peg.  v.  Taylor 
—Treatment  of  Epileptic  Insanity. 
By  epileptic  insanity  we  mean  that  form  of  mental  derangement 
in  the  antecedent  history,  oncome,  and  further  deveh:)pment  of  which 
we  recognise  an  intimate  connection  with  the  epileptic  neurosis.      Such 
functional  disturbances  of  the  nervous  mechanism  as  issue  in  what  are 
termed  epilepsies  may,   or  may   not,   have  for  their  accompaniment 
serious  mental  derangement.      Epileptic  fits  may  continue  for  years 
with  slight,  or  scarcely  appreciable,  mental  disturbance.     If,  however, 
the  epileptic  neurosis  presents  on  the  psychical  side  a  parallel  disorder 
of  mind,  we  speak  of -it  as  epileptic  insanity.     Epilepsies  may  develop 
during  the  course  of  other  cerebral  diseases  associated  with  insanity  as 
pure  accidents,  or  as  an  intercurrent  affection,  in  chronic  disorganisa- 
tion of  the  brain,  in  softening  from  embolism  or  thrombosis,  in  senile 
atrophy  and  decay,   during  the  progress  of  general  paralysis  of  the 
insane,  or  in  certain  cases  of  chronic  insanity,  the  epilepsy  then  being 
merely  an  accidental  complication  of  the  primary  affection,  and  depen- 
dent, probably,  in  part  upon  the  direction  taken  by  the  disease.     Nor 
can  it  be  questioned  that  epilepsy  may  arise  as  an  independent  and 
intercurrent  disturbance  in  subjects  mentally  afilicted,  having  no  direct 
connection  with  the  primary  cerebral   derangement,  and   it  becomes 
therefore  imperative  that  we  learn   to   recognise  such  morbid  linea- 
ments, so  to  speak,  in  the  mental  affection  as  indicate  its  kinship  to 

an  epileptic  neurosis. 

The  niental  derangement  of  the  epileptic  may  assume  the  form  of 
maniacal  excitement,  of  melancholic  depression,  of  mental  enfeeble- 
ment  or  dementia,  or  of  delusional  perversion  or  perversions  of  the 
moral  being ;  any  one  or  more  of  these  states  may  be  revealed  by  the 
patient.  As  in  all  cases  of  insanity  alike,  so  epileptic  insanity  notably 
presents  periods  of  heightened  functional  commotion,  with  intervals  of 
comparative  calm,  periods  of  sudden  and  excessive,  though  transient, 
dissolutions,  and  the  persistent  impairment  due  to  a  consta,ntly 
advancing,  though  gradual,  dissolution. 

The  immediate  results  of  an  epileptic  discharge  are  seen  in  the  deep 
reductions  of  epileptic  mania — a  transient  condition  only;  the  ultimate 
results  of  repeated  attacks  in  the  gradual  and  persistent  impairment  of 


009 


KPILEPTIC    INSANITY. 


tlie  mental  faculties  seen  in  epileptic  dementia.  Hence,  in  studying 
epileptic  insanity,  -sve  have  to  consider  the  acute  symptoms  or 
immediate  after-etlects  of  a  tit,  as  well  as  the  chronic  impairment 
presented  during  the  intervening  periods  between  the  attacks.  It  is 
not,  as  before  stated,  everrj  form  of  epilepsy  which  is  prone  to  issue  in 
mental  derangement,  if  by  epilepsy  we  mean  what  Dr.  Hughlings- 
Jackson  means;  that  is — "A  sudden,  rapid,  excessive,  occasional,  and 
local  discharge  of  cerebral  cortex."  * 

It  is  when  the  functional  disturbance  occurs  in  the  highest  nervous 
arrangements  of  the  cerebral  cortex  ("the  substrata  of  conscious- 
ness ")  that  the  mind  is  prone  to  suffer.  An  all-important  principle 
which  the  same  authority  has  taught  us  to  recognise  is  that,  in 
these  epileptic  seizures,  there  is  a  brutal  expenditure  of  force  wholly 
(jut  of  proportion  to  the  normal  physiological  outlay,  and  wholly 
inconsistent  with  continued  healthy  activity  of  the  parts  concerned. 
So  severe  is  the  explosive  violence,  that  the  nervous  tracts  traversed 
by  the  storm  are  so  damaged  as  to  be  rendered  transiently  incapacitated 
for  the  further  conduction  of  the  nerve  current,  and  the  centre  itself 
is  paralysed  for  the  time  by  its  enormous  expenditure  of  energy. 

If  we  attend  carefully  to  this  fact,  it  will  be  apparent  to  us  that  the 
transient  paralysis  of  the  motor  centres  and  ner^•es  is  not  the  only  or 
most  important  sequel  of  the  seizure.  We  are  aware  that  every  vivid 
mental  rehearsal  initiatory  of  an  act  (especially  when  the  action  is 
itself  suppressed)  is  attended  by  diffusion  currents,  which,  according 
to  the  physiological  law  of  least  resistance,  affect  first  the  smallest  mus- 
culature, e.g.,  the  eyeball  and  facial  muscles;  and  even  when  these  results 
are  not  apparent,  expend  themselves  along  intra-cerebral  tracts,  arous- 
ing sensory  excitations  and  correlated  feelings.  Just  as  the  substrata 
of  these  representative  states  affect  cortical  realms  other  than  those  in 
which  the  primary  excitation  arises,  so  likewise,  during  the  accom- 
plishment of  every  volition,  the  act  is  accompanied  by  so-called 
associated  actions  {e.g.,  the  associated  contraction  of  pupil  and  conver- 
gence of  eyeball),  and  this  series  of  associated  movements  is  a  very 
large  one  in  the  active  manifestations  of  the  organism.  But  this  is  not 
all.  We  know  that  both  the  initiatory  energising  of  the  cortex  and 
its  eventual  actualisation  are  attended  by  numerous  complex  feelings, 
such  as  a  memory  of  similar  acts  previously  performed,  of  their  results, 
and  of  the  notion  of  the  utility  of  the  act  to  the  "  individual's"  welfare. 
All  this  means,  of  course,  diffusion  currents  around  the  primary 
discharging  centre. 

If,  then,  all  energising  and  discharging  of  motor  centres  be  accom- 
panied by  such  effects  in  related  c<entres,  how  much  greater  will  be  the 
*See  West  Iiidiug  As>/him  Heports,  vol.  iii.,  p.  331. 


EFFECTS    OF    DIFFUSED    CURRENTS.  223    ' 

effect  when  the  motor  areas  are  overfloocled  by  the  brutal  explosiveness 
of  epileptic  discharges.  We  shall  then  have  not  only  the  paralysis  of 
the  conducting  tracts,  but  also  a  dangerous  flooding  of  those  delicate, 
yet  indefinitely  extended,  tracts  of  intra-cortical  nerve-tissue,  upon 
which  the  very  evolution  of  the  nervous  structure  depends.  If  we 
place  any  credence  whatsoever  in  the  theory  of  nerve-genesis  so 
elaborately  worked  out  by  Herbert  Spencer,  we  must  regard  this 
undue  foPCing"  of  nascent  nerve-tracts,  as  yet  incomplete  in  their 
formation,  as  a  most  serious  matter  in  epilepsy. 

It  is  important  to  observe  that  any  one  part  of  the  cerebral  cortex 
may  be  the  site  of  an  epileptic  discharge ;  and  hence,  the  resultant 
phenomena  will  be  co-extensive  with  the  multiplicity  of  cerebral 
functions,  and  as  varied  in  their  nature  as  tliey  are  varied.  Discharges 
in  motor  realms  will  thus  afford  endlessly  diversified  combinations  and 
sequences  of  spasms,  whilst  discharges  from  sensory  realms  will  like- 
wise implicate  correspondingly  complex  centres.  The  former  are  open 
to  objective  study ;  the  latter,  as  being  purely  subjective,  can  only  be 
gleaned  by  information  given  us  by  the  patient.  Again,  local  dis- 
charges initiated  in  motor  realms  may  spread  to  other  motor  areas,  or, 
from  being  of  hemispheric  origin,  may  become  bilateral  in  their 
distribution,  oi',  spreading  backwards  into  sensory  realms  and  the 
highest  and  most  complex  of  centres,  issue  in  loss  of  consciousness. 
As  regards  this  implication  of  consciousness,  "all  depends  on  the 
momentum  of  the  discharge,  and,  therefore,  on  how  far  it  spreads " 
{II iighlings- Jackson).*  In  like  manner  may  arise  pure  sensory  epilejD- 
sies,  with,  or  without,  loss  of  consciousness  in  the  full  acceptation  of 
the  phrase;  or  a  j)rimary  sensory  epilepsy  may  spread  into  more  purely 
motor  realms,  and  issue  in  general  convulsion,  the  discharge,  as  it  were, 
being  reflected  on  to  the  motor  sphere.  We  thus  see  how  infinitely 
varied  may  be  the  resultant  of  epileptic  discharge  from  any  unstable 
area  of  cortex.  In  unilaterally  commencing  convulsions,  viz.,  those 
due  to  local  discharges  in  one  hemisphere,  we  can  usually  trace  the 
spread  of  the  discharge  with  facility ;  this  is,  however,  not  the  case 
with  the  epileptic  seizures  associated  with  insanity.  Here  we  more 
frequently  observe  attacks  of  petit  mal,  or  else  that  form  of  g'rand 
mal,  in  which  the  loss  of  consciousness  is  early  and  comjjlete,  and  the 
spread  of  the  dischai'ge  so  rapidly  general  that  the  whole  body  is 
almost  simultaneously  affected  by  the  convulsion.  This  rapid  run- 
down of  mechanism,  comparable  to  the  rupture  of  the  mainsj^ring  of 
a  watch,  renders  it  impossible  in  most  cases  to  distinguish  any  sequence, 
in  the  resulting  spasms.  It  is  truly  a  universal  spasm,  ov,  to  use  Dr. 
Hughlings-Jackson's  vigorous  phi^ase,  "  a  clotted  mass  of  movements." 

*  Loc.  ell.,  p.  2GS. 


224  EPILEPTIC    INSANITY. 

In  like  manner  consciousness  is  then  lost  at  so  early  a  period,  and  this 
so  suddenly  that  the  patient  falls  instantly,  as  though  struck  senseless 
by  a  blow. 

The  discharge  from  seiisori/  areas  cannot,  from  the  very  nature  of 
the  case,  be  followed  ;  we  can  only  learn  the  existence  of  an  aura 
by  the  subsequent  statements  of  the  jjatient ;  but — impressed  only  by 
the  results  of  the  motor  discharges — we  must  not  lose  sight  of  tlie  fact, 
tliat  equally  powerful  discharges,  of  whicli  we  see  no  result,  may  pass 
along  sensory  areas  at  the  jieriod  when  consciousness  is  abolished. 
Undoubtedly  the  muscular  spasms  ai-e  likely  to  attract  to  themselves 
undue  attention  on  the  student's  jiart ;  and  he  forgets  for  the  time 
that  still  more  noxious  effects  ai'e  being  produced  in  the  areas  of 
mental  and  sensorial  activity  silently  and  concealed  from  his  view. 
It  is,  thei'efore,  all  the  more  important  that  one  should  keep  these 
unseen  results  in  mind,  and  watch  carefully  for  such  evidence  as  may 
arise  of  the  implication  of  the  sensory  portion  of  the  brain,  for  such 
evidence  is  forthcoming  at  certain  stages  of  the  affection. 

It  is  very  obvious  that  amongst  a  large  number  of  epileptics  in  our 
asylums  who  suffer  from  mental  dei'angement,  there  is  very  great 
divergence  in  the  history  and  progress  of  their  affection — the  pheno- 
mena of  their  disease  by  no  means  pi'esent  a  dead  uniform  level. 
Some  remain  inmates  for  very  many  years  with  the  intellect  but 
little  impaired,  and  then  only  at  those  periods  when  they  become 
subjects  of  epileptic  seizures ;  others  (with  few,  if  any,  convulsive 
attacks)  betray  at  long  intervals  periods  of  depression,  of  moroseness, 
or  of  excitement,  during  which  they  are  more  or  less  irresponsible 
for  their  actions ;  yet,  in  the  interim,  they  ai-e  perfectly  rational, 
cheerful,  amiable,  considerate  for  others,  and  obliging.  In  others 
again,  the  mind  becomes  rapidly  enfeebled ;  and  during  the  period 
of  their  "fits"  the  reductions  are  so  profound  that  absolute  dementia 
and  stupor,  or  perhaps  wild  ungovernable  fury,  prevail.  And,  yet 
again,  with  but  little  essential  difference  in  the  motor  disturbance 
of  two  cases,  the  wreck  of  mind  in  the  one  may  stand  out  in  strange 
contrast  with  the  clearness  of  intellect  in  the  other.  The  resulting 
dementia  therefore  (so-called  "effects  of  the  fits")  varies  very  con- 
siderably in  degree,  so  that  each  individual  case  may  be  unlike  the 
others  in  this  respect;  and  this  is  undoubtedly  dependent  upon  the 
varying  seat  of  the  primary  discharge  from  the  cortex.  To  quote 
Dr.  Hughlings-Jackson — "  From  this  it  follows  that  there  is,  scientifi- 
cally sjjeaking,  no  entity  to  be  called  epilepsy ;  but  innumerable 
different  epilej^sies  as  there  are  innumerable  seats  of  discharging 
lesions.  And  as  the  first  symptoms  in  the  paroxysm  is  the  first  effect 
of  the  discharge  of  the  centre  unstable,  any  two  paroxysms  beginning 


SENSORY    EPILEPSIES.  225 

differently  will  differ  throughout,  liowever  little."*  From  all  this  it 
becomes  sufficiently  obvious  that  we  must  not  rest  satisfied  with  a 
mere  observation  of  tlio  motor  discharge  exemplified  by  the  convulsive 
seizure  ;  but,  we  must  likewise  question  our  patient  closely  upon  his 
sensations  and  mental  disturbance  immediately  preceding  the  loss  of 
consciousness,  and  observe  closely  his  condition  as  presented  after  the 
paroxysm  and  up  to  the  full  re-establishment  of  conscious  activity. 

What  are  some  of  these  indications  of  discharges  in  sensory  realms  ? 
A  patient  at  the  West  Riding  Asylum  after  each  severe  attack  of  fits 
becomes  completely  blind,  and  gx'opes  about  on  hands  and  knees — 
epileptic  amaurosis  is,  however,  an  infrequent  effect  of  this  disease. 

Another  epileptic  becomes  hemianoesthetic  on  the  left  side  of  the 
body    after     certain    convulsive    seizures ;    and    this    anaesthesia    is 
attended  with  a  corresponding  state  of  the  retinal  fields ;  there  is  left 
homonymous  hemianopsia,    associated   also    with    impairment   of  the 
other  special  senses  of  the  same  side.      Indications  of  discharges  in 
sensory  realms  are  afforded  during  this  stage  of  re-energising,  by  the 
champing  movements  of  the  jaws,  with  corresponding  movements  of 
the  tongue,  probably  indicative,  as  has  been  stated  by  Terrier,  of  dis- 
charges from  the  centre  for  taste,  the  movements  being  thus  reflexly 
induced.     The  rubbing  of  the  hands  together — the  attention  of  the 
patient  evidently  being  attracted  thereto — probably  means  that  morbid 
sensations  are  referred  to  those  parts,     A  very  frequent  action  amongst 
such  patients  is  the  rubbing  of  the  open  hand  iipon  the  knees,  or  the 
slapping  of  their  thighs  with  the  palm  of  the  hand.    We  must,  however, 
be  careful  to  avoid  arriving  prematurely  at  a  decision,  that  this  is  due 
to  discharges  in  sensory  realms,  initiating  the  movement ;  it  certainly 
may  be  due  to   a  more   complex  mental  state.     Thus  one  intelligent 
patient  explained  this  action,  of  which  he  seemed  conscious,  by  saying, 
that  he  did  it  because  he  thought  he  could  "  bring  himself  by  this 
means  more  rapidly  out  of  the  fit."     Discharges  from  the  substrata  of 
visual  sensori-motor  areas  of  the  cortex   will  often  be  indicated  in 
fantastic  movements  of  the  hands,   as   though  the  patient  were  dis- 
entangling imaginary  skeins  of  thread  in   the  air.      Other  subjects, 
and   these   are    by   no   means    infrequent,    appear    to    be    following 
imaginary  objects  on  the  floor,  or  peer  in  some  one  direction;  or  again 
scrutinise  with   incessant    vigilance   the  floor   and  furniture    around 
them,  as  though  searching  for  some  lost  object.     With  all  this  there 
may  be  considerable  motor  automatism ;  the  subject  may  climb  upon 
tables  or  the  window-sills  still  seai'ching  apparently  for  some  object; 
or  he  may  remove  his  coat,  turn  out  the  contents  of  his  pocket,  &c. 
One  of  our  patients  invariably  after  his  fit  empties  his  pockets  on  the 

*  Loc.  ciL,  p.  270. 

15 


226  EPILEPTIC    IN'SAXITV. 

table,  secures  his  \n\)o,  and  placing  it  (althougli  empty)  in  liis  moutli, 
marches  to  and  fro  witli  a  self-satisfied  look  and  contented  mien. 

All  cases  of  epileptic  insanity  should  be  rigidly  studied  with  a  view 
to  (1)  eliciting  the  condition  of  mind  immediately  preceding  an  attack  ; 
(2)  the  essential  features  of  the  epileptic  seizures;  (3)  the  subsequent 
period  of  reinstatement  of  consciousness ;  (4)  and  lastly,  the  mental 
state  prevailing  in  the  period  intervening  between  the  "  fits."  We, 
therefoi'e,  divide  our  remarks  under  the  headings  of — Firstly,  the 
preparoxysmal  stage;  secondly,  a  premonitory  stage  (often  absent); 
thirdly,  the  paroxysmal  stage ;  fourthly,  a  post-paroxysmal  stage ; 
fifthly,  the  interparoxysmal  period. 

1.  The  Preparoxysmal  Stag"e. — The  epileptic  insane  are  especially 
prone  to  exhibit  indications  of  an  approaching  seizure  ;  nor  is  this 
surprising,  when  we  recall  how  slight  departures  from  the  normal 
state  of  healthy  cerebral  nutrition,  betray  themselves  in  all  our  sub- 
jective feelings  and  moods.  The  grave  nutritional  anomalies  upon 
which  an  explosive  neurosis  depends,  might  well  be  expected  to  declare 
its  advent  thus — subject,  of  course,  to  the  special  site  of  nutritional 
derangement.  A  change  in  character  is  thus  frequently  recognised 
during  a  period  of  hours  or  even  days  antecedent  to  a  seizure.  An 
able  and  intelligent  attendant  will  so  study  his  cases,  that  he  at  once 
detects  the  little  minor  changes  in  the  patient's  disposition,  indulges 
his  whims,  endeavours  to  sooth  his  morbid  irritability,  and  especially 
guards  the  subject  at  this  period  from  unnecessary  annoyances.  Thus, 
we  frequently  hear  excuse  made  for  some  patient's  lapses  of  temper, 
or  unseemly  behaviour,  "Oh,  he's  just  going  to  have  his  fits,  sir,  he 
will  then  be  all  right."  In  asylum  life,  amongst  the  intelligent  class 
of  nurses,  the  fact  is  uniA'ersally  recognised  that  a  premonitory  stage 
of  great  irritability  is  often  seen,  and  the  effect  of  a  convulsive  attack 
will  be  to  clear  up  the  mental  atmosphere. 

The  mental  disturbance  thus  preceding  the  epileptic  paroxysm  pre- 
sents very  variable  features — (1)  melancholic  gloom  and  despondency 
may  prevail;  (2)  hypochondi'iacal  perversions,  which  may  haA'e  been 
persistent  during  the[patient's  interparoxysmal  stage,  may  now  become 
exaggerated  and  intensified  ;  (3)  restless,  objectless  wandering  may 
indicate  the  uneasy  discontented  mind  ;  and  the  subject  may  complain 
of  this  unrest,  of  being  unable  to  follow  his  usual  occupation,  incapable 
of  keeping  his  mind  upon  any  subject  long  together;  he  cannot  read; 
his  sleep  fails  him  ;  he  becomes  indifferent  to  his  meals  and  inattentive 
to  his  wants  generally ;  (4)  a  vague  dread  of  impending  evil  is  occa- 
sionally expressed  ;  but  this]  is  moi'e  frequent  as  a  genuine  aui'a — a 
psychical  state,  the  immediate  accompaniment  of  the  commencing 
epileptic    discharge ;  ^(5)  joyous    elation    may   precede   an   attack,  a 


Tirn;  aura  epilkptica.  227 

goiionil  slatn  of  optimism  l)o  pi'csont,  often  associated,  liowevei",  with 
gross  egoistical  sentiments;  (6)  confusion  of  ideas,  diminislied.  vigour 
of  attention  and  memory  are  also  peculiar  to  this  stage ;  this  is 
the  first  symptom,  for  instance,  betrayed  by  an  epileptic  compositor 
employed  at  this  asylum  ;  with  him  there  is  also  at  this  time  a  notable 
degree  of  irritability  and  irrepressible  garrulity ;  (7)  delusions  of 
suspicion  are  a  pi'ominent  feature  before  epileptic  seizures  in  certain  of 
the  insane,  and  may  form  the  incitants  to  acts  of  dangerous  or 
homicidal  violence. 

An  inmate  of  the  West  Riding  Asyhim  almost  invariably  betrays  to  his 
attendant  this  state  of  mind  ;  he  stalks  up  and  down  the  wards,  assumes  a  defiant 
attitude  and  bearing  to  all  around,  keeps  a  vigilant  eye  upon  each  passer-by ;  and 
occasionally  beckoning  the  attendant,  reveals  to  him  privately  the  existence  of  an 
imaginary  conspiracy  to  poison  him.  This  patient  wholly  ignores  the  fact  that  he 
has  fits^"Oh,  they  say  I  take  fits,  you  know"  (with  an  incredulous  smile),  "but, 
I  know  what  ails  me;"  and  then  with  a  mysterioiis  air — "Wliat  they  put  m  my 
food  and  medicine  explains  everything."  At  times  he  openly  accuses  the  doctors 
of  drugging  his  food  and  drink,  and  always  in  the  stage  precedlnr)  convulsion.  In 
this  preparoxysmal  stage,  depression  always  prevails ;  the  convulsive  seizure 
occurs,  and  as  the  attendant  emphatically  and  truthfully  asserts — "  he  is  then  a 
new  man."  This  patient  also  believes  he  can  ward  off  the  effects  of  the  poison  hj 
drinking  his  own  urine,  which  he  has  been  detected  doing  on  more  than  one 
occasion,  and  with  this  avowed  object  in  view. 

2.  PpemonitOPy  Stag'e. — This  is  not  truly  a  stage,  but  the  first 
period  of  the  paroxysm  itself;  yet  it  is  convenient  to  consider  it 
separately  in  accordance  with  the  old  notion  of  the  phenomena,  the 
so-called  warnings  or  aUPSB.  In  fact,  the  phenomena  embraced  by  this 
period,  the  epileptic  aura,  are  but  the  subjective  aspects  of  the  nervous 
discharges  in  cortical  centres,  the  initiatoiy  symptoms  preceding  that 
loss  of  consciousness  which  leaves  the  remainder  of  the  convulsive 
paroxysm  minus  a  positive  mental  counterpart.  For  it  must  be 
remembered  that  in  all  these  excessive  discharges  along  highly 
specialised  sensori-motor  mechanisms  the  subjective  phases  are  of  but 
ti'ansient  duration,  only  during  the  earliest  peiiod  of  the  attack ;  the 
objective  are  obtrusively  present,  but  from  the  early  failure  of  con- 
sciousness have  no  mental  correlate.  Since,  however,  the  epileptic 
aura  constitutes  the  earliest  symptom  of  the  actual  discharge,  when 
correlated  with  the  physical  accompaniments  of  the  attack,  it  facilitates 
our  comprehension  of  cerebral  activity,  and  the  parallel  series  of 
psychical  manifestations.  To  the  student  of  psychology  it  is  of  intense 
interest,  and  should  be  studied  with  the  greatest  care. 

And,  in  the  first  place,  since  any  of  the  regions  of  the  cerebral  cortex 
(which  are  the  anatomical  substrata  for  all  forms  of  conscious  activity) 
may  be   the   site  whence   an    epileptic   discharge  originates,    so   the 


228  EPILEPTIC    INSANITY. 

phenomena  of  an  aura  may  be  co-extensive  witli  all  forms  of  sensation 
whatsoever,  and  may  even  be  constituted  Ijy  more  elaborate  foi-ms  of 
psycliical  activity.  The  sensation  constitutinf,'  an  aura  is,  therefore, 
referred  to  any  portion  of  the  environment,  includin;^  in  the  latter  term 
the  body  and  its  organs  generally.  We  tlms  may  get  aurce  of — (1)  the 
special  senses;  (2)  of  the  visceral  or  organic  sensations;  and  (3) 
intellectual  or  psychical  aura?.  A  few  remarks  on  these  sensations  will 
render  the  subject  clearer  : — 

(«.)  Special-Sense  Aurse. — It  must  be  remembered  that  in  the  five 
special  senses — taste,  smell,  touch,  hearing,  and  sight,  we  have  an 
ascending  scale  of  sensations  entering  more  and  more  intimately  into 
connection  with  our  intellectual  life.  TastC  and  smell  have  the 
least  intellectual  element,  and  are  specially  characterised  by  their 
slight  recoverability  in  idea,  i.e.,  in  persistence  or  capability  of  being 
recalled  in  the  absence  of  the  object;  although  both  are  capaljle  of 
much  improveability  by  education  {Bain).  On  the  other  hand,  tOUCh 
is  a  much  more  intellectual  sense,  highly  discriminative  as  to  locality, 
and  capable,  in  conjunction  with  other  senses  (and  especially  the 
muscular  sense),  of  giving  iis  ideas  of  the  form,  dimensions,  and  position 
of  objects  in  general ;  its  essential  intellectual  factor  is  dependent  on 
the  conjoint  agency  of  the  muscular  sense  {Bain).  Hearing"  and 
sight  attain  the  maximum  as  regards  intellectuality ;  are  highly 
co-operative ;  exquisitely  discriminative  in  their  powers ;  highly 
persistent  and  recoverable;  as  well  as  capable  of  almost  unlimited 
education.  Sig"!!!  is,  of  all  the  senses,  pre-eminently  characterised  by 
the  faculty  of  objectivising,  and  in  fact  enters  much  the  most  largely 
as  an  ingredient  into  the  constitution  of  object-consciousness.  On 
the  other  hand,  at  the  further  end  of  the  scale,  the  sense  of  taste  and 
of  smell  (and  still  more  notably  the  sensations  of  organic  life)  are 
characterised  by  their  inherent  subjectivity,  or  the  greater  difficulty 
experienced  by  us  in  discriminating  between  subject  and  object.  The 
drift  of  these  remai-ks  will  be  at  once  apparent  to  the  student  when  he 
considers  that  the  least  discriminating  and  most  subjective  of  these 
series  of  sensations  (the  organic  or  visceral,  and  taste  and  smell)  have 
least  connection  Avith  the  intellectual  operations  of  the  mind  ;  the 
most  discriminating  and  most  objectivising  (the  high  or  special  senses) 
have  intimate  connection  with  the  intellectual  operations,  and  that, 
therefore,  aurse,  consisting  of  the  former  sensations,  must  be  referred  to 
the  implication  of  the  substrata  of  the  crude  sensations  of  organic  life, 
and  the  emotions — those  of  the  latter — to  the  substrata  of  the  highest 
activities  of  the  mind,  although  they  also  enter  into  the  emotional  life 
of  the  being. 

Organic    Sensations.  —  The    innumerable    impressions   which    must 


OR(iANIC    AND    SPECIAL-SENSE    AUR^E.  229 

arise  momentarily  and  co-instantaneously  throughout  the  organism 
during  the  healthy  activity  of  all  its  tissues,  its  muscles,  bony  frame- 
work, viscera,  and  vascular  appaivitus  form  in  their  aggregate  what  are 
termed  the  sensations  of  org'anic  life.  Many  of  these,  such  as  the 
visceral  and  vascular,  have  phases  of  "  unfelt "  sensations,  or,  at  least, 
sensations  not  discriminated  from  the  vast  mass  of  sensations  created 
by  the  functional  activity  of  the  body  at  large,  with  periods  of  emphatic 
expression — e.g.,  hunger  and  thirst.  The  "  unfelt "  sensations,  however, 
rise  into  prominence  in  morbid  states  of  the  system,  and  we  then  get 
those  intensified  organic  sensations,  which  cause  much  discomfort  and 
contrast  with  the  normal  massive  feeling  of  hien-etre.  In  the  epileptic, 
likewise,  we  get  such  sensations  aroused  in  the  organic  aurse ;  they  are 
distinguished  by  the  massive  and  all-pervading  character  of  the 
sensation.  We  may  take  Professor  Bain's  classification  *  as  embi'acing 
these  sensations  of  organic  life,  which  are  thus  liable  to  derange- 
ment : — 

Sensations  arising  from 

(1)  Muscles.  (4)  Organs  of  circulation. 

(2)  Bones  and  ligaments.  (5)  ,,         respiration. 

(3)  Nerves  and  nerve  centres.  (6)  ,,         digestion. 
To  which  we  may  add  those  of  the  uriuo-genitoiy  apparatus. 

Visual  Aurce. — These  occasionally  precede  the  seizure  in  epileptic 
insanity,  but,  as  pointed  out  years  since  by  Sir  Crichton-Browne, 
aurse  are  not  of  frequent  occurrence  amongst  this  class  of  epileptics,  f 
When  they  do  occur,  the  visual  aurse  consist  usually  of  crude  sensa- 
tions, balls  of  fire,  coloured  light,  glittering  sparks,  &c.;  thus  G.M.  sees 
a  number  of  sparkling  stars  before  his  eyes,  all  around  "  looks  dim  ;  " 
and  if  he  holds  a  book  in  his  hand,  ere  it  falls  "  the  letters  all  run  into 
one  another."  W.B.  has  a  warning  described  as  a  doubling  of  objects 
around  him,  as  if  by  "  cross  sight,"  meaning  that  he  supposed  it 
was  due  to  a  transient  squint.  E-ed  and  blue  are  the  colours  more 
frequently  seen  in  these  visual  aura3  {Goicers). 

Auditory  Warnings. — These  are  less  frequent  than  the  visual ;  but  are 
occasionally  met  with  in  elaborate  form,  as  in  the  case  of  E.  C.  Dr. 
E-oss  speaks  of  hissing,  singing,  or  explosive  noises ;  of  a  noise  in  the 
ears,  followed  by  vocal  utterances,  in  some  cases  of  ordinary  epilepsy  | 
(p.  919).  Dr.  Gowers  speaks  of  a  crash,  a  whizz,  a  hiss,  or  whistle ;  or 
on  the  other  hand,  a  loss  of  hearing,  strange  stillness  preceding  the  loss 
of  consciousness.     These  are  rarely  recognised  in  asylum  epileptics. 

*  The  Senses  and  Intellect,  Alexander  Bain — "  Sensations  of  Organic  Life." 
+  West  Biding  Asylum  Medical  Bepoi'ts,  vol.  iii.,  p.  IGO. 
J  Quoted  by  Dr.  Hughlings- Jackson,  p.  303. 


:230  KPILKPTIC    IXSANIXy. 

Consciousness,  as  a  rule  (p.  G84),  is  in  thorn  too  early  lost  f(jr  these 
phenomena  to  occur. 

Gustatory  and  Olfactory  Aura. — These  are  the  least  frequent  form  of 
aunu  met  with  in  epileptic  insanity.  In  the  patient  J.  V.  the  con- 
vulsive seizures  were  invariably  preceded  by  such  affections  of  the 
sense  of  taste  as  would  justify  us  in  regarding  them  as  gustatory 
aurae.  The  intimate  connection,  between  the  sense  of  taste  and  that  of 
smell  renders  the  differentiation  between  hallucinations  of  these  senses 
dubious,  and  at  times  impracticable.  We  must  carefully  exclude  the 
instances  of  perverted  sensibility  which  so  frequently  engender  sense 
illusions  in  the  epileptic  subject,  giving  rise  to  delusions  of  being  fed 
upon  human  flesh,  or  similar  revolting  notions. 

Vaso-JIotor  Aurce. — This  form  is  exemplified  in  the  case  of  a  patient 
whose  fits  are  always  preceded  by  unilateral  vaso-motor  disturbance — 
marked  mottling  of  the  skin  of  the  palm,  associated  with  morbid  sensa- 
tions ;  the  patient  invariably  opens  the  hand  and  inspects  it  critically, 
turning  it  over  and  over  again,  and  feeling  the  skin  with  the  fingers 
of  the  other  hand.  Consciousness  is  then  lost,  and  the  arm  so  affected 
becomes  convulsed. 

(b.)  Visceral  or  Org'aniC  Aurse. — These  are  the  more  prevalent 
sensations  recognised  in  epilepsy,  as  stated  by  Sir  Crichton-Browne.* 
The  feeling  is  one  of  weight  at  the  epigastrium,  or  a  fulness  or  disten- 
tion of  this  region.  This  feeling  often  rises  to  the  throat,  causing  a 
sense  of  great  discomfort — the  patient  beginning  to  pull  at  his  collar  or 
necktie  as  if  to  loosen  it.  Occasionally,  the  sensation  creeps  up  to  the 
head,  becoming,  as  one  patient  described  it  to  me,  "  an  expansion  or 
swelling  of  the  head — an  opening  and  a  shutting."  Again,  the  epi- 
gastric sensation  may  be  one  of  actual  pain,  which  remains  until 
consciousness  is  lost.  Another  very  frequent  symptom  of  the  onset 
is  that  of  a  sinking  or  of  actual  j)ain  in  the  pra^cordia,  or  violent 
palpitation  of  the  heart.  A  feeling,  identical  with  the  globus  hystericus, 
is  also  very  frequently  observed  in  epileptic  insanity  (Goioers).  All 
these  aura?,  it  will  be  noted,  are  referi'ible  to  a  centric  disturbance  of 
the  vagus  and  spinal  accessory. 

3.  The  Epileptic  Paroxysm. — This  paroxysm  may  be  charac- 
terised by  the  predominance  of  the  mental  or  motorial  implication — 
that  is,  we  may  have  transient,  though  complete,  loss  of  consciousness, 
with  little  or  no  spasm ;  or  the  general  convulsions  may  be  the  pro- 
minent feature,  accompanied  by  early  or  later  loss  of  consciousness ; 
and  since  every  shade  of  interblending  of  such  phenomena  may  occur 
in  difterent  subjects,  so  no  shai-p  line  of  demarcation  can  be  drawn 
between  the  two  extreme  limits.     Classically,  and  for  convenience  of 

*  Loc.  cit. 


GRAND    MAL — PETIT    MAL.  231 

description,  we  recognise  the  two  forms,  called  respectively  le  grand 

mal  :in(l  le  petit  mal. 

(«.)  Grand  Mal. — An  aura  may  or  may  not  precede,  and  the 
patient,  if  standing,  may,  without  any  warning,  stagger  to  a  seat,  or 
fall  suddenly  down  on  the  face  or  back,  often  seriously  injuring  him- 
self There  may  be  the  "  epileptic  cry,"  which  is  very  frequent 
amongst  the  epileptic  insane.  It  may  consist  in  a  subdued  plaintive 
wail,  or  a  loud,  wild  scream,  or  a  succession  of  piercing  shrieks,  as 
though  the  subject  were  actuated  by  terror  j  at  times  it  is  a  mere  hoarse 
gurgling  in  the  throat,  or  a  loud,  prolonged  groan ;  all  probably  due 
to  the  sudden  forcible  expulsion  of  air  through  a  constricted  glottis 
during  the  tonic  spasms.  The  face  is  now  deadly  pale,  the  pupils 
dilate  widely,  and  consciousness  is  completely  lost.  The  convulsions 
beginning  by  tonic  spasm,  usually  cause  conjugate  deviation  of  the 
head  and  eyes  to  one  side,  to  which  the  body  tends  to  roll ;  the 
spasm  is  usually  more  marked  on  one  side  of  the  body  than  the  other ; 
the  chest  is  fixed,  and  respiration  being  arrested,  the  face  becomes 
now  injected  and  livid— the  tongue,  congested  and  swollen,  is  often 
forcibly  protruded  from  between  the  teeth,  the  veins  of  the  neck  are 
swollen  and  rigid,  and  intense  cyanosis  prevails.  The  position  of  body 
and  limbs  will  vary  much  in  each  individual  case,  depending  upon  the 
origin  of  the  centric  discharge,  its  strength  and  spread  to  collateral 
parts.  Flexion  and  extension  may  be  combined  in  different  limbs — or 
flexion  prevail  throughout — the  body  being  drawn  up  into  a  state  of 
emprosthotonos.  In  the  latter  case  the  patient,  if  sitting  or  standing, 
almost  invariably  falls  forwards ;  at  other  times  the  head  is  strongly 
drawn  backwards,  or  backwards  and  to  one  side,  so  that  the  subject  is 
twisted  round  in  his  chair  as  if  looking  over  his  shoulder.  The  tonic 
spasm  now  gives  way  very  gradually  to  clonic  convulsions — froth 
foams  from  the  mouth,  often  tinged  with  blood,  the  tongue  having  been 
caught  between  the  teeth  and  bitten  by  closure  of  the  jaw ;  the  fine 
vibratory  character  of  the  movement  becomes  coarser  and  broken  up 
into  rapid  rhythmic  movements,  which  eventually  are  large,  inter- 
rupted, and  cease  entirely  after  a  few  irregular  shock-like  jerks  of  the 
limbs.  The  clonic  spasms  last  from  half  a  minute  to  two  minutes,  and 
after  this  cessation  the  patient  lies  stupefied  and  breathing  stertorously. 
This,  the  third  period  of  the  fit,  is  very  variable  in  duration,  lasting 
from  a  few  minutes  to  as  many  hours.  There  is  a  gradual  return  of 
normal  breathing;  sensibility  and  motor  power  are  regained,  and, 
with  the  exception  of  some  heaviness  and  a  dazed  feeling,  the  previous 
condition  of  the  patient  may  appear  perfectly  re-established. 

(b.)  Petit  Mal. — In  these  attacks  there  may  be  nothing  observed 
beyond  momentary   loss    of  consciousness  and  pallor  of  face.      The 


232  EPILEPTIC   INSANITY. 

patient  may  be  sitting  or  standing  during  the  attack  ;  he  does  not  fall. 
He  may  drop  what  he  holds  in  liis  hands,  or  be  suddenly  arrested  in 
movement,  but  may  instantly  recover  liimself,  and  act  as  if  notliing 
unusual  had  occurred.  Esquirol  ^-elates  the  case  of  a  lady  equestrian 
who  liad  frequent  attacks  of  petit  mal  when  on  horseback,  yet  never 
fell  ofi'.  There  was  momentary  arrest  in  her  conversation,  the  bridle 
dropped  irom  her  hand,  but,  in  a  few  seconds,  she  had  recovered  and 
iinislied  the  sentence  interrupted  by  the  attack.  Very  often  the  face, 
subsequent  to  pallor,  becomes  flushed  (Gowers).  In  these  slight  seizures 
there  may  be  slight  facial  spasm — the  expression  is  momentarily  y?a;ec^; 
or  a  spasm  of  the  hand  may  occur,  or  a  more  noticeable  (but  limited) 
convulsion  of  very  transient  duration. 

One  of  the  premonitory  aurce,  before  noted,  with  some  vertigo  and 
reeling,  may  constitute  such  an  attack.  A  patient  may  be  subject  to 
such  attacks  for  years  without  a  single  seizure  of  grand  mal  occurring, 
or  these  two  forms  of  epilepsy  may  occur  indifferently,  now  one  and 
now  another,  in  the  same  subject — or  attacks  oi  grand  onal  interspersed 
with  the  minor  attack,  may  gradually  predominate  and  eventually 
wholly  replace  the  j^^tit  mal.  Thus  one  of  our  patients  at  the  West 
Riding  Asylum,  subject  to  such  seizures,  was,  while  sitting  up  in  bed 
one  morning,  requested  to  write  his  reply  to  a  question ;  he  wrote  a 
lengthy  answer,  interrupted  by  some  four  or  five  such  attacks.  There 
was  momentary  loss  of  consciousness — the  head  drooped  slightly,  the 
pencil  slipped  through  his  fingers,  but  was  almost  instantly  regained, 
and  the  sentence  Avas  continued  without  any  apparent  disconnection  of 
words  or  displacement  of  letters ;  the  interruption  was  so  slight  that, 
if  he  had  not  been  closely  watched,  the  conditioii  might  readily  have 
been  overlooked.  In  the  case  of  this  patient,  a  letter  might  \\a\e  been 
easily  written  by  him  showing  no  confusion  of  ideas,  and  consistent  in 
all  respects,  during  a  frequent  repetition  of  such  slight  seizures  as  the 
above ;  and,  in  a  medico-legal  sense,  this  is  of  the  utmost  importance 
to  recognise.  At  the  same  time,  these  slight  attacks  of  epilepsy  are 
well  known  to  issue  in  the  most  rapid  impairment  of  intellect — a  fact 
recognised  long  since  by  Esquirol.  This  is  because  the  disease  is  of 
the  "  very  highest  nervous  arrangements  in  the  whole  nervous  system, 
and  of  those  which  have  the  greatest  integration,  that  is  to  say,  of  the 
substrata  of  consciousness  "  (Ilughlings-Jackson).* 

4.  Post-paroxysmal  Period. — It  is  during  this  post-paroxysmal 
period  that  much  valuM))]e  information  may  be  gleaned,  as  the  mental 
automatism  then  displayed  is  in  many  cases  prolonged,  and  affords  us 
the  opportunity  of  careful  study.  Epileptic  mania  of  transient  duivt- 
tion  is  a  most  common  result  of  the  paroxysm,  but  it  is  by  no  means 

*  Loc.  at.,  p.  304. 


POST-PAROXYSMAL    PERIOD.  233 

.always  of  SO  fleeting  a  nature.  Cases  occur  where  the  maniacal 
excitement  extends  over  many  days  without  any  furthei-  epileptic 
seizures  intervening.  It  apparently  bears  no  direct  relationship  to 
the  severity  of  the  attack,  or  to  the  number  of  epileptic  seizures ;  it 
may  follow  slight  seizures  {petit  mal),  just  as  it  may  be  the  sequel  to 
the  major  convulsive  attacks  {grand  mal),  and  a  single  "fit,"  convulsive 
or  non-convulsive,  may  leave  the  patient  in  this  maniacal  condition  just 
as  frequently  as  a  succession  of  such  attacks.  This  want  of  connection 
between  the  epileptic  paroxysm  and  the  occurrence  of  a  maniacal 
outburst  is  perhaps  more  apparent  than  real.  We  are  apt  .to  lose  sight 
of  the  fact  that  the  slightest  seizures  are  just  the  very  cases  where 
consciousness  is  prone  to  be  most  impaired  or  involved,  and  where  a 
seizure  is  most  likely  to  be  wholly  overlooked  by  the  friends  or  even 
the  patient  himself;  and  thus  it  happens  that  a  paralysis  of  the  central 
hierarchy  of  the  nervous  system  may  so  withdraw  control  over  lower 
centres  as  to  issue  in  wild  excitement,  although  the  epileptic  seizure 
Avas  so  slight  as  to  be  scarcely,  if  at  all,  appreciable  to  the  onlooker. 
In  like  manner  the  major  discharge,  if  it  sta,rts  (as  in  cases  of  insanity 
it  most  frequently  does),  from  the  highest  cortical  centres,  may  also 
leave  these  parts  so  paralysed  as  to  result  in  a  post-epileptic  mania. 
One  single  attack  may  suffice  for  this  issue ;  all  depends  upon  the  site 
of  the  disease  being  in  the  realms  constituting  the  cerebral  substrata 
of  consciousness,  and  hence  the  vital  importance  of  noting  whether  in. 
our  cases  consciousness  is  lost  completely  or  only  partially,  and  whether 
early  or  later  in  the  course  of  the  paroxysm. 

The  attack  of  epileptic  mania  is  usually  highly  characteristic  in  all 
extreme  cases.  The  excitement  is  most  acute,  attended  by  almost 
ungovernable  violence  and  frenzied  fury — no  maniacs  show  such  blind, 
uncalculating  fury  as  the  epileptic.  On  this  account  he  is  one  of  the 
most  dangerous  subjects  we  have  to  deal  with  in  our  asylums,  for  the 
attacks  often  occur  with  slight,  if  any,  warning,  the  signal  first  given 
being  often  an  attack  of  brutal  and  impulsive  violence.  The  aspect  of 
the  patient  fully  accords  with  the  impulsive  conduct ;  he  is  usually 
pale,  ghastly,  the  eyes  staring  vacantly,  and  the  face  expressionless  or 
betraying  wild  and  passionate  emotions.  There  is  much  incoherence, 
yet  often  the  patient  utters  not  a  word,  but  struggles  wildly,  rushes 
madly  at  his  attendants,  and  appears  wholly  oblivious  to  existing 
conditions  around.  At  these  moments  he  is  in  peril  to  himself  and 
others;  and  suicidal  and  homicidal  acts  are  not  seldom  accomplished 
under  such  circumstances.  Occasionally  some  leading  idea,  usually  a 
delusional  notion  of  persecution,  is  expressed  by  the  subject  of  this 
mania.  It  was  before  stated  that  a  delusional  state  frequently  pre- 
cedes the  attack,  becoming  very  apparent  during  the  few  last  hours  of 


234 


KPILKPTIC    INSANITY. 


the  pre-paroxysmal  stage.     In  the  state  of  epileptic  mania  such  delu- 
sional perversions   are   very   likely   to   reappear,   and   to  prompt   the 
subject  to  deeds   of  violence.     There    is   a   tendency  apparent  after 
epileptic  seizures  in  the  insane,  for  ccjnsciousness,  on  its  reinstatement, 
to  be  occupied  immediately  with  the  subject-matter  of  thought  pre- 
ceding the  attack,  which  means  no  more  than  that  certain  nervous 
currents  established  just  upon  the  onset  of  the  seizure  are  liable  to  be 
re-established  immediately    as   consciousness  is    regained ;    what   was 
most  vivid  to  the  patient's  mind  before  the  "fit"  still  remains  most 
vivid  when  the  attack  is  over.     Thus,  a  question  put  to  the  subject 
and  replied  to,  just  before  a  convulsive  seizure,  will  often  be  replied 
to  again  immediately  at  the  first  look  of  recognition  on  regaining  con- 
sciousness.    A  female  epileptic,  e.g.,  asked  her  name,  replied,  "  I  am 
Annie  Thornbury,"  immediately  fell  in  a  fit,  and,  on  regaining  normal 
consciousness,  looked  around  and  said  again,  "I  am  Annie  Thornbury." 
An  epileptic  lad,  asked  his  name  and  age,  replied,    "Sixteen  years, 
Samuel  Speight";  he  thereupon  turned  pale,  uttered  a  loud  cry,  fell  to 
the  left  side,  the  head  and  eyes  turned  to  the  left,  the  left  arm  was 
■extended   and  convulsed;   he    then   turned  over  upon  his  face,  and 
•convulsively  moved  his  left  hand  wide-spread,  as  though  scrubbing  the 
boards.     On  regaining  consciousness  he  rose  to  his  feet,  and  looking 
straight  at  us,  said,  "  Sixteen,  I  am  Samuel  Speight."     So  also  in  the 
case  of  U.  C.  in  her  automatic  endeavour  to  pull  out  her  hair  (see  p.  235). 
We  mention  these  cases  more  particularly  because  they  appear  to  us 
■often  to  afibrd  a  clue  to  the  persistence  of  a  delusional  notion,  which, 
being  present  in  the  pre-paroxysmal  stage,  may  rise  into  being  in  the 
post-paroxysmal  period  during  the  reductions  of  this  stage,  and  issue 
in  immediate  action — suicidal  or  homicidal  attempts.      In  the  stage 
preceding  the  seizure,  they  may  have  little  influence  on  the  subject's 
conduct — he  then  retains  at  least  his  normal  self-control ;  but  during 
the  automatic  stage  of  post-epileptic  mania  they  may  be  of  terrible 
import. 

Erom  a  medico-legal  point  of  view,  we  cannot  too  strongly  insist 
upon  this  feature,  that  leading  ideas,  delusional  or  otherwise,  prevail- 
ing in  the  pre-paroxysmal  stage  are  likely  to  become  operative  in 
conditions  of  post-epileptic  automatism.  Wild,  delirious  excitement 
after  Jits  is  more  frequent  amongst  women  than  men  ;  they  lie  awake 
all  night,  chanting  aloud  a  song  or  sacred  air,  batter  their  bedroom 
doors  with  their  hands,  meet  one  with  defiant  glance,  and  are  utterly 
reckless  of  life  or  limb  if  interfered  with.  Fortunately,  their  very 
reductions  in  consciousness  prevent  them  from  providing  against  tact 
and  address  on  the  part  of  an  able  attendant,  so  that  they  are  readily 
overpowered  and  managed  in  most  cases. 


IIYSTEROID    ATTACKS    IX    EPILEPSY.  235 

It  is  not,  liowcver,  all  c;ises  of  epileptic  mania  which  exhibit 
these  wild  and  delusional  states.  Some  subjects  remain  incessantly 
garrulous,  and  ramble  in  an  incoherent  and  utterly  absurd  strain,  often 
peer  into  one's  face  with  a  scrutinising  look,  or  arrest  the  passer-by 
and  address  their  irrational  converse  to  him,  but  show  no  signs  of 
vindictiveness  or  passion.  Some  betray  their  excitement  by  incongru- 
ous and  unmeaning  gesticulation  and  grimace ;  others  by  incessant 
pacing  up  and  down  their  rooms,  exhibiting  strange  and  fantastic 
mannerisms.  One  epileptic  female  in  this  stage  invariably  hastens 
down  the  corridor  of  her  ward  and  kisses  the  pictures  hanging  to  the 
walls;  another  is  found  kneeling  with  clasped  hands  before  the  busts 
and  pictures.  A  case  of  epileptic  imbecility  in  whom  the  fits  are  now 
very  infrequent,  even  twelve  months  or  more  elapsing  between  each 
observed  seizure,  has  a  single  attack  of  convulsions  one  night,  and 
suffers  from  epileptic  excitement  for  a  fortnight  subsequently.  She 
lies  in  bed  in  a  huddled  heap,  covering  her  head  with  the  bed-clothes, 
muttering  incoherently.  When  disturbed,  she  utters  an  unintelligible 
jargon,  interspersed  with  curses,  and,  showing  her  teeth  with  a  fierce, 
vindictive  look — half  snarl,  half  grin — plunges  beneath  the  bedding. 
In  some  cases,  but  rarely,  the  acute  maniacal  excitement  sets  in 
immediately  ujDon  the  cessation  of  the  comatose  stage.  This  was 
notably  the  case  with  E.  C,  in  whom  a  wild  struggle  usually  ensued 
after  the  convulsive  seizure,  homicidal  and  suicidal  promptings  being 
prominent  features.  In  the  case  of  a  compositor,  already  alluded  to, 
in  whom  garrulity  augured  an  epileptic  seizure,  excitement  has  followed 
for  a  period  of  some  eight  or  ten  days.  During  this  attack  of  epileptic 
mania  he  would  wander  aimlessly  to  and  fro,  or  perform  peculiar 
gyrations,  talking  incoherently  in  a  loud,  declamatory  manner,  and 
indulging  in  a  rhyming  propensity  carried  to  a  ridiculous  extent. 

Hysteroid  Attacks. — These  are  not  at  all  infrequent  accompani- 
ments of  the  epileptic  seizure  in  the  insane.  Of  these  attacks  Dr.  Gowers 
says — ''Instead  of  presenting  such  automatic  action,  some  patients 
pass,  as  already  mentioned,  into  a  state  of  violent  hysteroid  convul- 
sions. This  sequel  occurs  chiefly  at  the  age  at  which  hysteria  is  met 
with,  under  thirty-five.  It  is  most  common  in  young  women,  frequent 
in  boys  and  girls,  occasional  in  young  men.  Hence  it  is  evidently  the 
result,  not  merely  of  the  preceding  epileptic  fit,  but  also  of  the  presence 
of  the  cerebral  state  which  underlies  the  manifestations  of  hysteria."* 

Case  ofE.  C. 
The  most  remarkable  case  we  have  met  with  occurred  at  the  ^Yest  Riding 
Asjdum  some  fourteen  years  ago. 

It  was  that  of  a  young  woman  aged  twentj^-eight,  and  single,  who  continued 
*  Op.  cit.,  p.  692, 


23G  EPILEPTIC    INSANITY. 

for  sixteen  months  under  our  observation,  and  who  for  the  first  twelve  months 
was  subject  to  epileptic  and  hysteroid  seizures,  whilst  during  tlie  latter  four 
months  she  was  completely  free  from  fits,  and  was  discharj^cd  recovered.  Her 
seizures  occurred  with  great  regularity  every  three  weeks,  and  lasted  from  three 
to  six  da3's — the  convulsive  seizures  occurring  both  night  and  day.  The  .symptoms 
of  the  several  stages  were  tlius  distributed. 

Pre-paroxysmal  Stage.  — For  some  days  before  a  seizure,  restlessness,  irritability, 
a  pale  and  anxious  look,  depression  amounting  to  despondency,  and  much  insomnia, 
were  noted.  Then  supervened  a  notable  peculiarity  of  manner,  and  she  confessed 
to  aural  hallucinations,  viz. — a  voice  repeatedly  calling  out,  "Kill  them!  kill 
them!  kill  them!"  She  was  at  this  time  distinctly  suicidal  and  homicidal  in 
her  impulses,  and  always  recognised  that  the  "fits"  were  pending  when  tlie 
phenomenal  voice  occurred.  Occasionally,  Muthout  a  seizure,  she  now  became 
very  violent  and  destructive. 

P remon'duru  Period. — Restlessness  more  urgent,  the  "voice"  more  imperative, 
then  the  sensations  of  "a  clock  "  within  the  head  "woimd  up  tighter  and  tighter," 
when  all  becomes  dark,  and  consciousness  is  abolished.  Asked  afterwards  to 
describe  the  "clock,"  she  defined  a  circular  sweep  about  4  inches  in  diameter, 
and  in  a  horizontal  plane  around  the  vertex  of  the  head ;  and  adds  that  if  her 
hair  were  cut  off  she  believes  it  would  obviate  the  tight  feeling  of  the  winding. 
{Her  last  automatic  act  after  an  actual  seizure  is  that  of  puUiiKj  out  her  hair.) 
Associated  with  the  "voice,"  she  occasionally  hears  bells  ringing,  and  has  a 
feeling  of  prickling  pain  within  the  eyeballs.  She  never  refers  to  her  suicidal 
impulses  or  to  the  "voice"  which  prompts  her  to  the  act  until  after  the  S'.'izure  ; 
but,  she  often  refers  to  the  clock  as  it  begins,  crying  out,  "The  clock,"  "the 
clock,"  and  then  becomes  unconscious.* 

Tlie  paroxysm  was  invariably  notable  for  the  following  features  : — 

(a.)  Deliberate  rise  of  temperature  and  quickened  pulse  during  the  quarter  of 
an  hour  preceding  the  fit. 

{h.)  Peculiar  recurrence  of  convulsive  seizui-e  in  series  of  threes  or  sixes. 

(c.)  Extraordinary  periodicity  of  both  diurnal  and  nocturnal  seizures. 

(d. )  Post-epileptic  automatism  replaced  hy  hysteroid  seizures  occasionally  ;  or 
l)y  wild  ei)i]eptic  mania  with  determined  suicidal  or  homicidal  impulses. 

The  rise  of  temperature  usually  amounted  to  a  degree  above  noi-mal,  occasionally 
higher ;  the  pulse  often  rising  to  130  before  loss  of  consciousness  ;  it  was  also 
peculiar  in  the  fact  that  when  the  convulsion  was  arrested  bj'  chloral,  the  viae  in 
temperature  still  took  place,  and  became  even  more  marked  when  the  lit  was  thus 
suppressed.  The  attack  of  convulsions  presented  two  varieties — in  one,  com- 
mencing almost  simultaneously,  and  occurring  bilaterally  ;  in  the  other,  beginning 
on  the  right  side  and  spreading  to  the  left,  "Violent  twitching  of  right  angle  of 
mouth ;  the  head  drawn  slowly  to  the  right ;  right  arm  affected  by  clonic  spasm — 
then  the  left  arm  and  hand  ;  eyeballs  drawn  upwards ;  the  feet  raised  from  the 
floor,  the  left  first,  then  the  right,  both  rigid  and  quivering.  Whole  fit  lasted 
about  ten  seconds,  and  terminated  suddenly  with  complete  muscular  flaccidity." 
Another  series  of  attacks  is  thus  described.  "  Twitching  of  both  eyes  and  angles 
of  mouth  ;  then  clonic  spasms  of  both  arms  and  legs,  a  preliminary  tonic  spasm 
hardly  observed ;  next,  tonic  spasm  of  the  chest  muscles  with  a  loud  scream  ; 
universal  clonic  spasms ;  relaxation  of  muscles,  and  tit  over.     Three  or  six  such 

*  This  case,  of  which  the  main  features  are  given  here,  has  been  published  in 

detail  in  the  West  Eiilinfj  Asylum  lieporls,  vol.  vi. 


CASE    OF    IIYSTERO-EPILEPSY.  237 

attacks  occur  in  succession,  the  last  always  followed  by  closure  of  the  eyes,  which 
tliroughout  tlie  attack  had  been  kept  open. "  Then  after  tliree  or  four  minutes'  calm 
tlie  liiisteroid  attack  occurred  ;  the  eyes  opened  suddenly,  staring  vacantly,  the  head 
was  drawn  rigidly  back,  the  body  arched  Ijackwards  in  a  position  of  opistliotonos 
for  about  fifteen  to  thirty  seconds  ;  then  the  head  was  thrown  violently  forwards 
and  backwards  several  times,  and  a  severe  struggle  ensued  in  which  she  had  to  be 
forcibly  restrained  by  several  nurses  to  prevent  her  rushing  to  the  window  or 
injuring  herself  or  others.  When  watched  (unknown  to  herself)  in  the  padded 
room  at  nio-ht,  the  same  attacks  occur,  and  in  the  succeeding  hysteroid  seizure  her 
body  has  been  tossed  from  end  to  end  of  the  room  against  the  pads  by  the  violence 
of  the  contortions  ;  her  Ijedclothes,  also,  after  such  attacks,  were  invariably  torn 
to  shreds. 

The  epileptic  seizures  above  described  maintained  an  extraordinary  periodicity 
in  their  sequence  ;  each  series  of  fits  almost  invariably  taking  place  at  about  the 
same  hours  throughout  both  day  and  night.  Several  features  of  the  case  would 
naturally  suggest  a  purely  hysterical  origin  for  such  an  attack ;  but  that  the 
seizures  were  genuinely  epileptic  associated  with  sequent  hysteroid  seizures,  was 
conclusively  shown  by  associated  conditions  which  were  invariably  present ;  these 
were — (1)  initial  rise  of  temperature  and  pulse;  (2)  aura  of  the  "clock"  followed 
by  intense  pallor  of  face  ;  (3)  extreme  dilatation  and  inequality  of  pupils,  the  right 
always  the  larger  ;  and  (4)  well-marked  nystagmus. 

The  number  of  epilei)tic  attacks  occurring  in  this  subject  varied  from  SO  to  120 
(both  day  and  night),  and  these  became  somewhat  less  frequent  and  less  severe 
towards  the  fourth  or  fifth  day  as  the  termination  of  the  attack  approached.  The 
following  note  made  by  the  writer  at  the  time  illustrates  the  thermal  disturbance 
preceding  the  attack  : — "Immediately  preceding  the  attack  a  rise  of  temperature 
occurred  of  1°  to  1  "2°  Fahr. ;  and  at  the  struggle  a  still  further  rise,  often  to  the 
extent  of  1°,  or  even  more.  The  temperature  then  slowly  fell  again  to  98 '6°,  and 
on  one  occasion  as  low  as  98  "2°,  except  when  two  fits  succeeded  each  other  quickly. 
On  the  occurrence  of  six  struggles,  the  total  elevation  of  temperature  recorded 
was  fully  2  ■2°,  slowly  falling  to  99  "2  during  the  following  hour  and  a-half.  The 
previous  administration  of  chloral  invariably  arrested  the  rise  occurring  hefore  the 
fit ;  hut  at  the  exact  rnoment  when  the  fit  loas  expected,  instead  of  a  convulsive 
seizure,  there  was  sudden  profound  sleep  and  a  rise  of  about  six-tenths  of  a  degree." 

Another  peculiar  phenomenon  was  noted  after  the  convulsive  seizures  had 
ceased  and  whilst  a  still  childish,  pettish  mood  prevailed,  with  distinct  alienation, 
the  temperature  taken  at  periods  corresponding  to  the  time  of  her  fits  was  found 
from  six-tenths  to  1  '8°  above  normal,  although  at  other  periods  of  the  same  day 
(not  corresponding  to  the  hour  of  a  fit)  the  temperature  was  98 '4°.  "As  these 
periods  arrived  she  would  become  greatly  depressed,  often  starting  up  and  com- 
plaining to  the  nurse  of  her  low  spirits."  At  these  times  (although  naturally  an 
intelligent,  bright,  and  cheerful  young  woman)  she  would  remain  for  days  subse- 
quent to  the  attack,  childish  in  her  pursuits,  woiild  make  dolls'  clothing,  and 
fondle  a  doll  like  a  child  not  out  of  her  teens  ;  was  capricious  in  likes  and  dislikes, 
pettish  and  ill-humoured.  This  case  illustrates  in  a  forcible  manner  most  of  the 
very  variable  features  of  epilepsj'.  The  premonitory  depression ;  the  tendency 
to  distinct  mental  aberration ;  hallucinatory  phenomena ;  the  aura,  epileptic, 
hysteroid  and  cataleptic  states ;  impulsive  homicidal  and  suicidal  violence  ;  and 
the  resultant  mental  reductions  following  the  more  marked  post-epileptic  automatic 
stages. 


238  Kl'ILCPnC    INSAMTV. 

Epileptic  Katatonia. — We  may  here  advert  to  cases  of  so-called 
katatonia— a  tLim  intended  by  Kalilbaum  to  include  those  multiple 
symptoms  of  stupor,  cataleptiform,  and  ecstatic  states,  with  phases  of 
dumbness  or  reiterative  speech — all  running  a  certain  cyclical  course  ; 
and,  according  to  this  author,  constituting  in  their  ensemble  a  distinct 
morbid  entity,  as  characteristic  as  general  paralysis.  Such  symptoms 
are  not  infrequent  in  epileptic  insanity  ;  they  especially  prevail  in  the 
mental  alienation  of  puberty  and  adolescence,  in  the  puerperal  forms 
of  insanity,  and  arc  closely  associated  with  the  vice  of  onanism.  The 
more  closely  we  study  these  cases  of  katatonia  described  by  Kahlbaum 
and  other  writers,  the  more  convinced  are  we  that  we  are  dealing, 
not  with  any  distinct  patliological  entity,  but  with  some  of  the  multiple 
phases  of  hysteria.  Melancholia  attonita  closely  approximates  to  the 
states  to  which  we  now  allude. 

Status  EpileptiCUS. — The  very  extraordinary  periodicity  of  the 
attacks  narrated  in  the  last  case  is,  of  course,  exceptional ;  yet  a  well- 
marked  tendency  to  the  periodic  return  of  epileptic  seizures  has  long 
been  recognised,  and  especially  emphasised  by  Reynolds — "A  large 
number  of  epileptics  have  their  seizures  every  day,  every  two  weeks, 
three  weeks,  and  four  weeks,  while  only  a  much  smaller  number  suffer 
at  such  irregular  intervals  as  cannot  be  thus  expressed."  This  opinion 
can  be  endorsed  by  all  who  have  had  acquaintance  with  epileptic 
insanity,  for  it  is  undoubtedly  true  that  these  subjects  exhibit  a 
notable  degree  of  such  periodicity.  A  periodic  recurrence  is  more 
frequent  in  the  female  than  the  male ;  but,  this  is  attributable  to  the 
associated  menstrual  derangements  so  often  connected  with  the 
epileptic  convulsion.  The  number  of  seizures  varies  greatly  in  some 
individuals:  an  enormous  number  have  been  recorded  within  short 
periods  of  time ;  thus,  a  patient  at  the  West  Riding  Asylum  had 
1,849  convulsive  attacks  recorded  in  a  period  of  fifteen  days;  and 
Delasiauve  mentions  an  epileptic  who  had  2,500  attacks  in  one 
month.*  In  general  a  patient  has  one,  two,  or  three  attacks  during 
the  day  or  night,  recovering  full  consciousness  between  each  seizure, 
possibly  passing  many  days  before  a  recurrence. 

But  if  the  attacks  succeed  each  other  rapidly,  and  consciousness  be 
not  restored  between  the  convulsive  seizures,  if  fit  succeed  fit  at 
intervals  of  a  few  minutes  only,  the  patient  remaining  comatose,  we 
have  developed  what  has  been  termed  the  epileptic  StatUS,  a 
condition  of  most  serious  import.  The  pulse  and  breathing  become 
quickened,  and,  as  Bourneville  first  indicated,  the  temperature  rises  to 
105°  or  107°,  with  deepening  coma  and  stertor ;  the  patient  is  liable  to 
sink.  As  the  fatal  termination  approaches,  the  convulsions  become 
*  Quoted  by  Eoss,  op.  clt. ,  p.  932. 


EPILEPTIC    AUTOMATISM — INTEH-PAROXYSMAL    .STATE.  239 

more  frequent,  a  few  seconds  only  intervening  between  each  discliai-ge, 
so  that  at  times  they  appear  ahnost  continuous,  a  fresh  dischai-ge  Ix'ing 
only  recognised  as  a  slight  increase  in  the  intensity  of  the  convulsions. 
When  this  period  arrives,  however,  the  epileptic  discharge  becomes 
progressively  feebler,  and  the  fit  may  be  characterised  by  a  slight 
turning  of  the  head  and  eyes  to  one  side,  with  slight  clonic  movements 
of  the  limbs,  or  merely  convulsive  twitchings  of  one  side  of  the  mouth 
without  conjugate  deviation.  The  conjunctivae  are,  of  course,  quite 
insensitive,  the  pupils  being  widely  dilated  and  fixed  to  the  strongest 
glare  of  light,  while  the  face  and  body  are  bedewed  with  a  cold  sweat. 
Often  the  temperature  exhibits  unilateral  deviations,  being  highest,  by 
a  degree  or  more,  on  the  side  first  (or  most)  convulsed.  If  the  patient 
recover,  the  fall  of  temperature  is  most  rapid  on  this  side  until  a 
balance  is  established ;  and  subsequently,  an  equable  and  continuous 
decline  of  temperature  proceeds  on  both  sides.  Many  epileptics  are 
subject  to  these  occasional  outbursts  of  convulsions  passing  into  the 
status  ;  these  cases  an  observant  medical  officer  soon  learns  to  recognise, 
and  experience  teaches  him  the  necessity  of  keeping  them  for  pro- 
longed periods  upon  bromide  treatment.  In  the  section  on  treatment 
of  epilepsy  we  shall  deal  with  this  serious  condition  in  detail ;  suffice 
it  here  to  remark,  that  prompt  and  vigorous  measures  must  at  once  be 
adopted  if  we  wish  to  save  our  patient's  life.  The  mortality  from  the 
status  epilepticus  is  said  to  be  due  to  (a.)  collapse,  and  (b.)  meningitis, 
the  fits  ceasing,  the  patient  becoming  delirious,  developing  bed-sores, 
&c.  We  cannot  say  that  this  latter  termination  has  been  seen  by  us ; 
the  mode  of  death  has  always  been,  according  to  our  experience  in 
asylum  practice,  exhaustion  with  hypostatic  congestion  of  the  lung. 

Epileptic  automatism,  of  a  most  elaborate  kind,  is  a  prominent 
and  often  j)erilous  feature  in  some  epileptics  after  their  fits  ;  its  interest 
as  a  medico-legal  question  is  great.  Thus  we  constantly  obsei-ve 
patients  at  this  stage  perform  not  only  the  most  incongruous  acts,  but 
carry  out  what  would  seem  to  be  complicated  purposive  acts,  to  which 
they  are  entirely  oblivious  on  return  to  normal  consciousness.  They 
will  pick  the  pockets  of  fellow-patients ;  pui'loin  articles  in  the  most 
deliberate  fashion ;  conceal  weapons,  such  as  knives,  &c.,  in  their 
pockets  or  beneath  their  clothing ;  and  follow  out,  as  before  stated,  a 
series  of  actions  in  accordance  with  the  promptings  of  some  leading 
delusional  idea,  such  as  a  somnambulist  would  perform.  The  case  of 
W.  T.,  detailed  below,  illustrates  this  point  forcibly,  and  still  more  so 
the  case  following  it  (York  Assizes). 

Interparoxysmal  State. — We  come  now  to  the  mental  condition  of 
epileptics  in  general  at  the  periods  intervening  between  their  seizures, 
when  the  immediate  effects  of  the  attack  are  past,  aiul  prior  to  the 


240  EPILEPTIC    INSANITY. 

disturbance  engendered  by  tlie  approacli  of  a  fi-esh  series  of  fits.  In 
fcict,  we  have  to  study  the  peculiar  characters  of  the  epileptic  neurosis, 
and  the  permanent  mental  reductions  whicli  Ijecorae  established,  in 
consequence  of  the  diseased  state  of  the  nervous  centres  and  the  dis- 
ordered function.  In  reviewing  a  large  number  of  the  epileptic  inmates 
of  an  asylum,  it  becomes  evident  that  they  may  roughly  be  arranged 
in  four  classes. 

(a.)  A  small  section  is  comprised  by  those  who,  upon  the  subsidence 
of  the  seizures,  exhibit  a  perfectly  normal  state  of  mind ;  no  emotional 
or  intellectual  disturbance  can  be  traced  by  the  strictest  scrutiny,  and 
their  conduct  (consistent  in  every  respect)  enables  thera  to  take  up  any 
emi^loyment  for  which  they  were  fitted,  and  carry  on  responsible 
functions  in  various  departments.  Why  are  they,  then,  inmates  of  an 
asylum?  Because  their  epileptic  seizures  are  preceded  or  followed  by 
such  transient  mental  aberration,  or  by  such  reductions  as  render  them 
at  these  times  a  risk  to  themselves  and  others ;  or,  because  the  interval 
between  their  attacks  is  so  short  and  exposes  them  to  such  risks  in 
their  usual  avocations,  that  they  demand  continuous  supervision  and 
treatment.  Outside  an  asylum  this  class  is  a  large  one ;  comprising, 
as  it  does,  all  those  in  whom  the  nature  of  the  epileptic  seizure  is  such 
as  to  affect  the  mental  faculties  but  slightly,  if  at  all,  even  in  the 
pre-paroxysmal  as  well  as  post-paroxysmal  stage.  It  is  a  well  recognised 
fact,  which  the  student  must  bear  carefully  in  mind,  that  certain  forms 
of  epilepsy  with  frequent  fits  may  last  for  many  years,  and  yet  the 
mental  faculties  remain,  in  the  interval  between  the  successive 
seizures,  perfectly  intact ;  nor  must  he  be  misled  by  any  such  notion 
(as  we  once  heard  expressed  in  a  court  of  j  ustice),  that  becaitse  a  man 
has  had  Jits  for  viany  years  his  mind  must  necessarily  have  suffered 
jjermanently ;  although,  of  course,  in  a  large  number  of  cases,  the 
presumption  is  in  favour  of  such  implication. 

(6.)  Then  there  are  those  cases  of  epilepsy  in  whicli  the  affective 
sphere  of  the  mind  is  almost  exclusively  at  fault ;  where,  with  a  normal 
and  often  vigorous  intellect,  we  still  find,  as  a  permanent  residue,  an 
emotional  perversion,  which  maps  them  off  from  the  healthy  com- 
munity, and  which  reveals  itself  by  certain  oddities,  eccentricities  of 
conduct  and  want  of  control ;  or,  by  an  abnormal  welling-up  of  feeling, 
an  instability  of  emotions  highly  characteristic  of  the  class.  To  this 
section,  also,  belong  many  who  might  be  called  moral  imbeciles. 

(c.)  Then  there  is  the  extensive  class  of  those  in  whom  the  main 
feature  is  intellectual  perversion ;  in  whom  delusional  states  are  rife ; 
and  in  whom  the  passions  are  violent  and  uncontrolled ;  a  class  which 
comprises  some  of  the  most  dangerous  elements  amidst  our  asylum 
communities,  since  with  all  the  natural  impulsiveness  of  the  epileptic, 


EPILEPTIC    HYPOCHONDRIASIS.  241 

the  delusional  states  engendered  render  tliem,  at  all  times,  apart  from 
their  paroxysmal  seizures,  pi'one  to  acts  of  desperate  violence. 

((/.)  Lastly,  there  are  the  advanced  cases  of  epileptic  dementia,  in 
which  the  reductions  are  so  extreme,  that  the  higher  emotions  and 
moral  sense  are  well-nigh  extinct,  and  the  intellectual  operations 
correspondingly  enfeebled ;  and  in  whom  the  mental  life  of  the  indi- 
vidual consists  of  the  lower  animal  instincts  and  passions,  and  the 
impulses  towards  their  immediate  gratification.  None  of  the  insane 
arrive  at  a  more  degraded  level  than  the  epileptic  dement ;  none  of 
them  exhibit  more  rejDulsive  traits — more  obnoxious  passions ;  and  in 
none  does  the  physique  undergo  sucha  corresponding  degradation  in  type. 

Amongst  the  several  arbitrary  divisions  thus  enumerated,  there  are 
certain  mental  characteristics  common  to  the  whole  class  which  largely 
enter  into  what  we  mean  by  the  "  epileptic  neurosis."  Notably  pro- 
minent is  the  tendency  to  self-engrossment  which  may  pertain,  not 
only  to  the  bodily  sensations,  giving  rise  to  the  grosser  forms  of 
hypochondriasis,  but  also  to  the  passions,  and  feelings,  and  senti- 
ments of  the  individual,  which  are  morbidly  dwelt  upon  and,  so, 
intensified.  Any  bodily  discomfort,  however  trivial,  is  thus  apt  to  be 
exaggerated  into  a  serious  ailment,  and  incessant  complaint  is  made  to 
the  medical  attendant  as  to  the  state  of  the  stomach,  the  bowels,  the 
heart,  &c.  The  epileptic  is  essentially  a  hypochondriac;  on  the  other 
hand,  irritability  of  temper,  to  which  he  is  prone,  is  sure  to  find  an 
object  of  complaint ;  imagined  ills  are  conjured  up,  and  he  conceives 
himself  the  most  injured  individual  in  his  ward.  In  like  manner,  his 
sentiments  respecting  his  own  abilities  and  aptitudes  undergo  a  like 
intensification,  and  he  becomes  vain  and  self-laudatory.  This  rise  in 
the  self-consciousness  begets  an  egoistic  state  of  mind,  which  renders 
the  epileptic  the  most  selfish  and  narrow  of  all  beings,  and  the  corre- 
sponding decline  of  object-consciousness  is  well  illustrated  in  his 
utter  regardlessness  of  the  time  or  comfort  of  others — his  incessant  and 
wearying  importunity  and  demands  upon  the  patience  of  his  fellow- 
creatures,  his  obtrusive  display  of  self-interested  motives — in  fact,  in 
the  profound  decline  of  the  altruistic  sentiments  and  higher  moral 
incentives  to  action.  Opposed  to  this  moral  decadence,  at  first  sight, 
might  appear  the  statement  that  the  epileptic  often  betrays  a  notable 
degree  of  religiosity ;  above  all  others  of  the  insane,  he  is  distinguished 
for  his  adherence  to  religious  rites  and  formalities ;  importunate  in  his 
requests  to  attend  religious  services,  addicted  to  repeating  Scripture 
texts,  to  constant  perusal  of  the  Bible  and  devotional  works,  to  singing 
sacred  hymns,  to  falling  on  his  knees  in  prayer  upon  inapt  occasions 
and  with  an  obtrusive  show  of  mock  piety ;  he  but  illustrates  another 
phase  of  the  rise  of  self-consciousness  as  it  pertains  to  the  religious 

IG 


242 


EPILEPTIC   INSANITY. 


sentiments.  His  religious  life  fails  in  its  intellectual  grasp  ;  it  is  essen- 
tially egoistic,  shallow,  selfish,  and  similar  to  the  undeveloped  phases 
of  the  religious  life  in  a  low  grade  of  civilisation.  The  grossest  animal 
passions  find  their  gratification  pari  passu  with  this  mock  display  of 
pietistic  fervour,  with  a  sanctimonious  bearing  and  a  profuse  indul- 
gence in  religious  cant,  and  with  apparent  consistency  in  the  epileptics 
mind.  The  realisation  of  the  religious  life  in  action — the  objectivising  or 
actualisation  which  is  its  proper  sphere — is  at  fault;  there  is  a  decline  in 
object-consciousness ;  hence  he  finds  no  difficulty  in  reconciling  these  feel- 
ings with  the  continuous  gratification  of  low  and  depraved  instincts. 

The  lower  types  of  epileptics  also  exhibit  a  characteristic  low 
cunning  and  deceit ;  they  are  treacherous  in  their  dealings  with  their 
associates,  thievish  in  their  propensities,  and  when  arraigned  upon  a 
charge  of  misconduct,  will  meet  it  with  the  coolest  audacity,  and  lie  to 
the  bitter  end.  The  epileptic  shows  a  tendency,  akin  to  that  of  the 
hysteric  subject,  to  malingering.  Both  will  falsely  accuse  of  violence 
those  with  whom  they  are  aggrieved;  Avill  treasure  up  a  tooth,  or 
wilfully  pull  out  their  hair  by  the  handful,  and  present  it,  to  counten- 
ance their  charge ;  and  will  cunningly  call  to  their  defence  certain 
delusional  notions  to  which  they  may  be  prone  during  the  period 
of  their  seizure,  if  they  can  benefit  their  position  thereby — this 
tendency  should  be  carefully  borne  in  mind.  All  the  apparent 
delusional  statements  of  an  epileptic  are  not  to  be  received,  except 
with  ca\ition,  as  their  sole  object  may  be  to  obtain  some  indulgence  or 
requirement,  and  especially  so  with  the  hypochondriacal  subject.  Con- 
sorting with  this  moral  decadence  the  epileptic  is  eminently  instinc- 
tive and  impulsive,  a  feature  demanding  the  utmost  tact  in  his 
management  at  the  hands  of  those  who  undertake  his  case ;  his  conduct, 
when  aroused,  is  peculiarly  brutal  and  ferocious,  and  often  charactei'ised, 
like  liis  actions  during  periods  of  epileptic  automatism,  by  wholly 
disproportionate  and  excessive  violence. 

The  reaction-time  in  epileptic  insanity  is  delayed  as  will  be 
apparent  from  the  following  series,  taken  indiscriminaitely  from  a 
large  number  of  cases  examined  : — 


Reaction-time  in  Epileptic  Insanity. 


AcocsTic  Stimulus. 

Optic  Stimulus. 

J.  J.  M.,    . 

•20  of  a  second. 

•23  of  a  second. 

J.  v.,        .       .       . 

•21 

•25 

F.  P.,         .         .         . 

•18 

•23 

J.  D.,         .         .         . 

•19 

•21 

W.  P., 

•17 

•19 

R.  H 

•24 

•26 

A.  D., 

•28 

•29 

FORENSIC    ASPECTS    OP    EPILEPTIC    INSANITY.  243 

MediC0-leg"al  Relationships. — No  form  of  insanity  so  frequently 
presents  itself  to  the  medico-legal  expert  as  epileptic  insanity,  and 
this  from  two  very  obvious  reasons.  Epilepsy  is  a  disease  to  which 
the  criminal  class  are  peculiarly  subject ;  it  is  the  associate  of  in- 
temperance, moral  degradation,  vicious  bodily  organisation,  and 
the  very  varied  heritage  of  a  criminal  parentage ;  and,  in  the 
second  place,  of  all  cerebi'al  diseases  it  is  the  one  which  tends  to 
engender  impulsive  fox-ms  of  insanity,  as  well  as  to  degrade  and 
brutalise  the  victim's  nature,  whilst  the  phenomena  of  post-epileptic 
automatism  often  lead  to  acts  of  apparent  criminality  although 
the  subject  is  really  an  irresponsible  agent.  First,  then,  we  would 
ask  :  How  far  does  the  fact  of  epilepsy  render  its  subject  irresponsible 
for  his  actions  1  It  is  obvious  from  the  foregoing  considerations  that 
epileptic  insanity  no  more  presents  a  uniform  series  of  symptoms  than 
do  the  physical  accompaniments  of  the  epileptic  paroxysm  always 
assume  the  same  orderly  sequence  of  events.  Just  as  it  is  allowable 
to  speak  of  epilepsies,  rather  than  epilepsy,  as  regards  the  physical 
features  presented  by  the  attack ;  so  the  correlated  mental  symptoms 
exhibit  very  varied  forms  of  insanity.  And,  apart  from  the  varying 
type  of  the  insanity,  we  also  witness  a  great  variation  in  degree  ;  so  that, 
we  may  not  only  find  that  our  patient  is  prone  to  melancholia,  mania, 
delusional  insanity,  impulsive  insanity,  dementia,  but  also  that  all  these 
anomalies  may  vary  in  degree  from  the  slightest  to  the  most  intense 
manifestations,  or  long  periods  may  intervene  Avherein  no  mental 
anomaly  presents  itself  It  cannot  be  questioned  that  many  epileptics 
suflfer  little,  if  any,  mental  derangement  jDrior,  or  subsequent,  to  their 
seizures ;  and,  that  the  interparoxysmal  period  'tna.j  be  one  consistent 
with  the  most  perfect  sanity,  with  vigorous  mental  activities,  with 
intellectual  capacities  of  a  high  order,  and  with  special  aptitudes  and 
executive  address  which  enable  them  to  hold  positions  of  trust  and  high 
responsibility.  It  is  only  as  the  immediate  forerunner  or  outcome  of  the 
epileptic  seizure  that  they  may  be  truly  irresponsible  agents.  The  "fits" 
may  even  be  of  frequent  occurrence,  and  yet  the  interval  between  two 
consecutive  seizures  may  present  no  obvious  mental  derangement.  We 
must  not,  therefore,  assume  that  because  a  patient  is  epileptic  and  has 
many  fits,  even  with  mental  disturbance,  that  he  is  necessarily  alienated 
in  the  interval  between  such  attacks,  and  therefore  irresponsible  for  his 
actions.  The  longer  the  interval  between  two  seizures,  cceteris  jid-rihuti, 
the  greater  the  presumption  also  that  the  mental  faculties  may  escape 
implication ;  and  since  frequent  occurrence  of  fits  is  damaging  to  the 
mental  constitution,  especially  fits  of  a  certain  type,  so,  conversely,  we 
anticipate  more  interparoxysmal  mental  derangement  in  cases  of 
rapidly-recurring  attacks.     In  fact,  the  2)'>'oxinii(!j  of  an  act  of  outrage 


244  KPILEI'TIC    INSANITV. 

or  violence  to  an  epileptic  seizure  directly  favours  the  presumption  of 
mental  impairment ;  and,  in  this  connection,  it  must  be  sti-ongly  in- 
sisted upon  that  the  mental  disturbance  following  upon  a  single 
epileptic  iit  is  frequently  prolonged  over  many  hours  or  even  days. 

The  question  might,  therefore,  be  naturally  put:  if  an  act  of  violence 
be  committed  by  an  epileptic  a  day  or  two  subsequent  to  an  epileptic 
seizure,  is  the  agent  to  be  regarded  as  responsible  for  his  conduct, 
because  on  the  expiration  of  a  further  period  he  is  found  perfectly 
sane  1  Obviously,  from  what  was  implied  above,  we  are  not  justified 
in  assuming  that,  since  he  is  free  from  obvious  mental  derangement 
a  week  or  so  subsequent  to  his  seizure,  he  was  not  alienated  for  some 
liours,  nay,  days,  after  the  attack.  Acts  of  suicidal  or  homicidal 
nature  may  be  committed  subsequent  to  epileptic  seizures  as  the  out- 
come of 

(a.)  Genuine  automatism  ; 

(b.)   Or  as  an  incontrollable  impulse  devoid  of  motive ; 

(c.)    Or  during  the  blind  fury  of  epileptic  mania ; 

(d.)  Or,  lastly,  the  act  may  be  instigated  by  the  promptings  of  a 
deluded  mind. 

It  is  essential  that  we  clearly  distinguish  these  states  in  investi- 
gating the  hidden  springs  of  a  murderous  or  suicidal  attempt. 

First,  as  regards  epileptic  automatism,  it  must  be  remembered 
that  actions  of  very  considerable  complexity  may  be  performed  whilst 
the  individual  is  a  mere  machine  acting  like  a  purely  reflex  mechanism, 
the  patient  upon  return  of  normal  consciousness  being  completely 
oblivious  to  the  act  which  he  has  perpetrated ;  in  this  condition  he  is 
neither  conscious  of  the  act  performed  nor  of  its  consequences. 

Incontrollable  impulse  is  another  form  of  morbid  activity  which 
reveals  itself  in  the  subjects  of  epilepsy  ;  like  the  motor  explosivencss 
of  the  convulsive  paroxysm,  a  leading"  idea  may  prompt  to  action 
with  an  imperative  demand  which  brooks  no  denial.  Epileptics  are 
often  conscious  of  this  dire  necessity ;  it  may  ai'ouse  within  them  the 
ancient  docti-ine  of  fatalism ;  they  may  be  terrified  at  their  own  help- 
lessness, and  implore  us  to  impose  restraint — a  plea  the  veiy  last  to  be 
neglected  by  the  medical  adviser.  The  impulsiveneSS  of  the  epi- 
leptic is  proverbial,  and  should  never  be  lost  sight  of  in  questions 
involving  his  responsibility ;  for,  where  other  evidence  of  mental  im- 
pairment is  wanting,  where  delusion  cannot  be  traced,  where  the 
subject  was  possessed  of  presumably  normal  consciousness  at  the  time 
of  his  act  of  violence,  still  a  factor  of  the  gravest  moment  in  this  line 
of  conduct  may  have  been  a  notably  diminished  self-control.  The 
essence  of  an  impulsive  act  is,  of  course,  its  spasmodic  suddenness  and 
want  of  apparent  motive.     The  lawyer  naturally  enquires  for  a 


IMPULSE DELUSION — MALINGERIXG.  245 

motive,  which,  if  found,  he  regards  as  evidence  presumptive  of  the 
volitional  nature  of  the  act,  and  subversive  of  the  doctrine  of  its  im- 
'puhive  character.  He  assumes  that  the  presence  of  motive  warrants 
him  in  regarding  the  epileptic  as  fully  conscious  of  the  deed  he  per- 
forms— of  its  nature  and  probable  issue.  We  should  be  most  guarded 
in  accepting  this  conclusion. 

The  motives  prompting  to  action  in  healthy  mental  operation  are  so 
complex  as  often  utterly  to  defy  our  most  careful  scrutiny  ;  much  more 
so  will  this  be  the  case  when  dealing,  not  with  an  organism  which  re- 
acts within  fairly  constant  or  calculable  limitations,  but  with  the 
perturbed  brain  of  the  epileptic,  in  which  the  line  of  conduct  is  subject 
to  no  method  of  calculation.  Even  if  there  be  a  strong  colouring  of 
evidence  that  the  act  was  the  outcome  of  apparent  motive,  the  natural, 
and  often  inborn,  impulsiveness  of  the  epileptic  neurosis  should  warn 
us  seriously  against  arriving  at  too  hasty  a  conclusion  upon  this  head. 

In  the  third  place,  outi'ageous  actions  may  be  committed  durino-  the 
wild  mania  incident  to  epilepsy ;  in  these  cases,  of  course,  no  doubt 
can  arise  as  to  the  agent's  utter  irresponsibility.  The  natUFG  of  SUCh 
acts  in  these  latter  cases  will  often  be  characterised  by  their  frightful 
violence;  the  crime  can  thus  often  be  instantly  identified  by  its  blind, 
aimless,  uncalculating,  utterly  reckless  fury,  which  at  once  stamps  it  as 
the  work  of  an  epileptic  {^Maudsley).  There  are  in  these  murderous 
outrages  of  epileptic  mania  indications  of — (1)  an  utter  loss  of  control, 
(2)  of  deep  reductions  in  consciousness,  (3)  of  violent  explosive  conduct. 

Lastly,  the  act  may  be  done,  as  stated  above,  at  the  instig'ation  of 
a  deluded  mind.  The  epileptic  insane  are  not  necessarily  (or  even 
frequently)  deluded,  and  we  should  look  with  some  suspicion  upon  cases 
of  affirmed  delusion,  fostered  by  those  whose  paroxysms  are  infrequent, 
or  occur  at  long  intervals.  The  delusions  of  epilepsy  arise,  as  before 
stated,  during  the  eai'ly  and  premonitory  stages  of  the  attack;  the 
paroxysm  itself  often  having  the  effect  of  clearing  ofi"  the  mental 
clouds,  and  of  leaving  the  subject  often  better  than  before  the  seizure. 
One  crucially  important  feature,  however,  to  recognise  from  a  medico- 
legal standpoint  is,  that  the  delusions  prevailing  prior  to  the  epileptic 
seizure  may  be  operative  immediately  subsequent  to  the  fit,  and  before 
consciousness  is  completely  regained.  This  has  already  been  noted, 
but  its  importance  merits  emphasis  here.  When  an  epileptic  sutlers 
notably  from  delusion  prior  to  his  seizures,  the  outcome  of  his 
paroxysm  should  be  carefully  watched  [E.  C,  W.  T.). 

It  is,  of  course,  of  the  greatest  importance  to  recognise  any  connec- 
tion existing  between  the  conduct  of  the  epileptic  and  the  previously 
existing  delusional  state ;  since,  if  the  act  be  the  direct  outcome  of,  or 
can  be  traced  up  to,  such  an  aberrant  state  of  mind,  he  must,  of  course, 


246  EPILEPTIC    INSANITY. 

be  regarded  as  an  irresponsible  agent.     The  depth  of  reduction  in  these 
epiloi)tic  derangements  should  receive  attention. 

(a.)  Was  the  act  characterised  by  complete  automatism  1 

(b.)  Or  was  he  sufficiently  conscious  as  to  recognise  its  nature  1 

(c.)  Or  was  he  sufficiently  conscious  to  recognise  its  criminal  nature 
also — the  distinction  between  right  and  wrong,  and  the  probable  issue  1 

(d.)  Or,  even  if  the  latter  was  the  case,  was  it  the  outcome  of 
insane  delusion,  or  perpetrated  as  a  purely  incontrollable  impulse  1 

Maling'ering". — Epilepsy  is,  as  is  well  known,  frequently  feigned 
by  the  criminal  community ;  often  with  the  object  of  exciting  com- 
miseration and  extorting  pecuniary  assistance ;  and  this  is  done  with 
considerable  cunning  and  success  by  some.  But,  though  the  com- 
munity generally  may  Vje  imposed  upon  with  ease,  it  is  scarcely  possible 
that  one  well  versed  in  the  subject  could  be  deceived  by  the  most 
cunning  and  expert.  The  intense  pallor  preceding  the  strong  con- 
vulsions, the  widely-dilated  pupils,  the  disturbed  organic  functions, 
and,  often,  the  minute  extravasations  of  blood  over  the  surface  of  the 
body  cannot  be  assumed ;  and  would,  therefore,  lead  to  speedy  detec- 
tion of  the  fraud.  It  is  not  so  with  the  forms  of  mental  derangement 
associated  with  epilepsy,  the  delusional  perversions  of  this  stage  being 
readily  counterfeited,  and  by  no  means  easy  of  detection. 

The  plea  of  epilepsy  is  one  so  frequently  established  in  defence  of 
cases  of  outrage,  assault,  or  murder,  that  the  possible  feigning  of  this 
disease  and  its  forms  of  mental  disturbance  should  always  be  borne  in 
mind.  The  difficulty  is  greatly  enhanced  by  the  fact  that  the  criminal 
class  are  so  much  associated  with  those  subject  to  epilepsy,  that  they 
acquire  considerable  address  in  feigning  the  disease ;  and  they  have 
.sufficient  cunning  to  assert  the  presence  of  hallucinatory  and  delusional 
states  if  thereby  they  can  gain  their  ends. 

And  here  we  are  face  to  face  with  another  difficulty  :  the  genuine 
epileptic  is  also  notably  cunning,  and  often  much  given  to  shamming 
— not  bodily  ailments  alone,  but  mental  also — usually  with  the  object 
of  obtaining  some  desired  indulgences  ;  it  is  by  no  means  infrequent 
to  discover  an  epileptic  girl  "  shamming"  a  fit,  just  as  others  affirm  they 
suffer  excruciating  pain,  &c.  Such  a  subject,  arraigned  on  a  trial  of 
murder,  would  be  most  likely,  if  he  thought  the  plea  of  insanity  would 
save  his  life,  to  reproduce  his  former  experiences,  and  assume  delusions 
from  which  he  might  have  suffered  at  times.  In  the  case  of  Beg.  v. 
Taylor,  where  the  prisoner  was  charged  with  the  murder  of  his  infant 
child  and  of  the  police-superintendent,  it  was  believed  that  the  state- 
ments advanced  by  the  defence  as  evidence  of  delusional  perversion 
(obtained  J  zfs^  prio7-  to  his  trial)  were  of  this  nature.  The  closest  obser- 
vation and  repeated  examination  during  his  early  imprisonment  wholly 


CASE    OF    REG.    V.    TAYLOR.  247 

failed  to  elicit  a  deluded  state  ;  and  it  is  strongly  suspected  that  the 
frequent  subsequent  examinations  which  he  underwent  suggested  to 
his  mind  the  policy  of  malingering.  That  he  was  fully  aware  of  the 
gravity  of  his  oflfence,  and  the  probable  issue,  was  made  apparent  by 
his  statement  to  a  fellow-prisoner  on  the  night  preceding  the  trial, 
that  he  would  probably  have  to  go  to  a  lunatic  asylum ;  a  recognition 
of  his  position  wholly  inconsistent  with  the  assumption  of  the  defending 
counsel,  that  the  prisoner  was  a  complete  mental  wreck.  That  he  was 
subject  to  delusions,  about  the  period  of  his  "  fits,"  could  not  be 
doubted ;  and  that  the  murderous  act  was  instigated  by  such  delusion 
is  equally  free  from  objection;  yet  the  facts,  that  a  period  of  some 
months  had  elapsed  without  such  a  seizure,  and  that  no  clue  to 
delusion  was  forthcoming  until  just  prior  to  his  trial,  were  strong 
evidence  in  favour  of  his  malingering.  In  this  case  also  no  epileptic 
seizure  had  occurred  for  three  months  subsequent  to  the  murder  ;  and 
the  question  as  to  the  very  existence  of  epilepsy  in  his  case  required 
examining.  It  was  found  that  his  neighbours  and  fellow-townsmen 
knew  little  or  nothing  about  his  "  fits,"  and  evidence  as  to  such  could 
only  be  obtained  from  interested  parties — his  wife,  parents,  and  a 
lodger.  But  here  again,  on  the  other  hand,  it  was  obvious  how 
readily  a  genuine  description  of  epileptic  seizures  may  be  recognised 
from  a  feigned  account.  A  most  graphic  account  of  grand  mal  and 
'pet'it  mal  was  given  by  each  witness  separately  examined,  consistent 
with  each  other  in  every  detail,  evidence  which  most  distinctly  would 
have  broken  down  if  the  witnesses  had  not  actually  and  indivi- 
dually witnessed  the  seizures.  Another  question  of  interest  in  this 
case  was  the  actual  condition  of  the  prisoner's  mind  at  the  time  of  the 
act.  Was  the  act  characterised  by  impulsiveness,  or  was  it  the  out- 
come of  the  delusions  previously  fostered  %  There  is  little  room  for 
doubt  that  the  act  was  deliberate  and  intentional,  according  to  his  own 
account.  He  had  for  hours  barred  himself  within  his  house,  handlina:  a 
loaded  gun ;  his  pockets  contained  several  loaded  cartridges ;  and  it 
was  only  after  watching  his  pursuers  for  some  long  time  through 
the  window  of  the  house  that  he  eventually  took  deliberate  aim 
"behind  the  ear"  of  the  police-superintendent  and  discharged  his  gun. 
He  both  intended  to  kill  his  victim  and  fully  recognised  the  surround- 
ing circumstances.  .  In  short,  the  act  was  very  clearly  not  the  impulsive 
act  of  epileptic  furor,  but  the  well-planned  and  determined  act  of  a 
deranged  mind  prompted  by  delusion.*     One   of  the   most  striking 

*  As  these  sheets  are  passing  through  the  press,  I  hear  that  this  criminal-lunatic 
has,  in  a  fit  of  maniacal  fury,  destroyed  his  eye-sight  by  self-iuUicted  violence,  at 
the  Broadmoor  Criminal  Asylum  ;  and,  in  a  letter  subsequently  dictated  to  his 
wife,  he  says:— "Old  Satan  told  me  to  pull  out  my  eyes,  and  1  camiot  see  at  all  now. " 


248  KPILKPTIC    INSANITY. 

instances  of  liallucination,  or  the  aura  epileptica,  becoming  the  motive 
for  action  during  the  automatic  stage  i.s  illustrated  by  a  aise  whei-e  the 
subject  (who  was  undoubtedly  neurotic,  of  a  very  bad  stock,  but  who 
was  not  known  to  have  previously  suffered  from  epilepsy),  as  he  lay  in 
bed  beside  his  wife,  imagined  he  saw  two  burglars  rifling  the  contents 
of  a  chest  in  his  room.  He  spi'ang  out  of  bed,  and,  according  to  his 
own  statement,  as  he  rushed  from  the  room  for  help,  he  saw  one  of  the 
men  rush  upon  his  wife  and  strike  at  her  with  a  hatchet.  He 
remembers  nothing  more ;  but  was  found  by  a  policeman  (to  whom  he 
made  the  above  statement)  wandering  in  the  streets,  vacant  and  con- 
fused, and  holding  a  hatchet  in  his  hand.  It  appeared,  from  all  the 
evidence  produced  in  this  case,  that  the  poor  man  had  a  fit,  jjreceded 
by  the  visual  aura  of  the  burglars  in  his  room,  that  the  idea  of  the 
hatchet  prompted  him  to  rush  down  stairs  to  the  cellar  in  order  to 
secure  that  wea^oon,  and  during  this  automatic  stage  he  murdered  his 
wife.  No  case  could  more  forcibly  indicate  the  friglitful  risk  to  which 
the  aura  may  expose  certain  epileptics  during  the  post-convulsive  stage, 
and  the  necessity  for  close  supervision. 

Treatment. — No  drug  has  so  powerful  an  influence  over  the 
convulsive  attacks  of  chronic  epilepsy  as  the  bromide  of  potassium,  or 
the  combinations  of  bromine  with  sodium  and  ammonium.  The  first- 
mentioned  is  most  relied  upon,  and  may  be  administered  for  very 
lengthened  periods  of  many  months  without  inducing  hroniism,  and 
with  very  marked  benefit.  There  are  a  certain  proportion  of  the  epileptic 
insane — doubtless  the  minority — in  whom  the  bromides  are  of  little  or 
no  avail ;  but  by  far  the  lai'ger  number  exhibit  a  notable  reduction  in 
the  frequency  and  severity  of  their  fits  upon  their  administration.  The 
bromides  have  no  immediate  action  in  checking  the  fits,  so  that  a 
somewhat  prolonged  treatment  is  necessary  ere  the  desired  effect  is 
obtained ;  hence,  if  the  attack  is  threatening  (owing  to  the  severity 
and  rapid  succession  of  the  convulsions)  to  pass  into  the  status  epile^}- 
ticus,  it  is  of  little  use  depending  upon  the  bromide  for  cutting  short 
the  attack.  For  tins  purpose  we  have  no  rival  to  chloral,  which, 
given  in  sufficiently  large  doses,  rarely  ftxils  to  arrest  the  seizures. 
Where  there  is  an  enfeebled  heart  and  torpid  circulation,  large  doses  of 
chloral  naturally  suggest  great  risk — hypostasis  certainly  is  to  be 
feared ;  yet  the  imminent  peril  from  exhaustion,  due  to  the  repeated 
seizures,  renders  it  necessary  to  administer  this  drug,  with  certain 
precautions.  It  is  Avell,  first,  to  inject  subcutaneously  from  -jVjy  to 
-j^  of  a  grain  of  atropine  if  a  large  dose  (40  grs.  to  a  drachm)  of 
chloral  has  to  be  given.  Thus  shielded,  a  sufficient  dose  of  the  drug 
may  be  given  to  completely  arrest  the  attack,  a  procedure  preferable, 
we  thiidc,  to  the  more  frequent  administration  of  small  doses.     It  is 


TREATMENT   OF    EPILEPTIC   INSAMTY.  249 

imper.ative  in  these  cases  that  nourishment  be  given  in  the  intervals 
between  the  fits ;  and,  if  the  patient  be  too  unconscious  or  torpid  to 
swallow,  it  must  be  introduced  by  the  stomach  tube.  In  a  few  cases 
vomiting  may  occur  and  food  so  given  be  constantly  rejected,  and  yet 
a  nutrient  enema  may  be  retained,  and,  with  this  chloral  may  be 
combined.  It  should  always  be  borne  in  mind  that  chloral  has  its-; 
role  in  the  emergencies  of  epileptic  outbursts,  bromide  in  the  more 
prolonged  treatment.  Many  patients  in  asylums  cannot  live  without 
the  bromide  treatment ;  if  it  be  neglected,  the  fits  become  at  once  so 
frequent  that  they  run  imminent  risk  of  passing  into  the  epileptic 
status,  and  dying  thus.  Hence  it  is  that  in  most  asylums  we  tind 
chronic  epileptics  who  for  years  together,  with  short  intervals  of  rest, 
are  taking  bromides  continuously,  who  maintain  their  health  well, 
have  hearty  appetites,  are  cheery  and  industrious,  and  whose  fits, 
recurring  at  long  intervals,  would  at  once  assume  a  serious  character 
if  the  drug  were  suspended. 

Prolonged  treatment  usually  entails  in  many  a  very  troublesome 
form  of  acne.  It  is  customary,  in  such  cases,  to  suspend  the  drug  for 
a  few  weeks,  and  order  the  jiatient  saline  laxatives;  but  it  may  equally 
well  be  met  by  the  combination  of  a  small  dose  of  the  liquor  arsenicalis 
with  the  bromide  salt.  In  fact,  arsenic  may  be  given  in  all  cases  alike 
with  decided  benefit  from  the  outset. 

On  the  other  hand,  a  certain  proportion  of  our  epileptic  insane  have 
a  sei'ies  of  convulsive  attacks  periodically,  often  with  intervals  of 
months  between.  During  the  intervening  period  they  are  free  from 
excitement,  active,  and  cheerful  subjects,  but  when  once  the  fits 
are  about  to  occur  they  become  querulous,  hypochondriacal,  and 
violent.  Such  patients  may  often  have  their  attacks  cut  short  by 
a  dose  of  chloral,  and  by  removal  from  sources  of  irritation  to  the 
quiet  of  a  darkened  room ;  nor  do  they  by  any  means  invariably  call 
for  prolonged  bromide  treatment.  To  select  those  cases  suitable  for 
bromide  treatment  from  those  who  can  be  safely  kept  without  this 
drug,  requires  a  prolonged  experience — each  case  must  be  judged  upon 
its  individual  merits;  but,  in  all  alike,  bromide  treatment  should,  in 
the  first  place,  be  adopted  with  the  hope  of  possibly  lessening  the 
frequency  and  alleviating  the  severity  of  the  attacks. 

In  the  epileptiform  attacks,  such  as  characterise  the  history  of  many 
cases  of  general  paralysis,  we  shall  find  that  the  bromides  are  of  no 
avail ;  here  chloral  must  be  our  sheet-anchor.  The  long-continued 
maniacal  excitement  of  epileptics  is  best  met  by  repeated  doses  of  the 
asylum  "green  mixture" — i.e.,  bromide  in  combination  with  the  tinc- 
ture of  Indian  hemp  ;  half-drachm  doses  of  the  former,  with  one-drachm 
of  the  latter,  given  twice  or  thrice  daily,  rarely  fail  to  alleviate  tlie 


250  GENERAL    PARALYSIS. 

excitement.  In  the  more  serious  delirious  outburst  of  epileptic  furor,  ifc 
is  well  to  administer  chloral  at  intervals,  followed  by  the  former  mixture. 

How  bromide  acts  upon  the  nervous  centres  we  do  not  know;  by 
what  means  it  induces  more  stability  of  the  discharging  cells  is  at 
present  a  complete  mystery.  "  Bromides  are  said  to  cause  contraction 
of  the  small  arteries  of  the  brain,  but  it  is  exceedingly  doubtful  whether 
any  part  of  their  infliionce  in  epilepsy  is  due  to  this  action."     {(Jowers). 

Iron,  given  in  combination  with  bromide,  is  of  indubitable  value  in 
all  such  epileptics  as  exhibit  any  notable  disturbance  at  the  menstrual 
periods,  at  which  time  there  is  often  not  only  a  succession  of  fits,  but 
iilso  much  maniacal  excitement.  Its  vise  is  also  called  for  in  all  the 
hysteroid  attacks. 

GENERAL  PARALYSIS  OF  THE  INSANE. 

Contents.— Prodromata — Egoism— Early  Moral  Perversion — Failure  of  Re-repre- 
sentative States  —  Enfeebled  Attention  —  Transient  Amnesia  —  Vaso-motor 
Derangements — Early  Paresis— Second  Stage— Delusions  of  the  Paralytic  and 
Monomaniac— Vanity  and  Decorative  Propensities- Sexual  Perversions— Facial 
Expression — Articulatory  Imjiairment  — Cerebral  Seizures — Syncope— Epilepsy 
(J.  F.) — Unilateral  Twitching  (J.  S.)— Epileptiform  Attacks — Conjugate  Devia- 
tion—  Case  of  H.  P. — Apoplectiform  Seizures  — Monoplegia- Hemiplegiai  — 
Spastic  and  Paralytic  Myosis— Mydriasis  and  Amaurosis — Reflex  and  Associative 
Iridoplegia — Statistical  Tables— Consensual  jSlovements— Retiex  Dilatation — 
Reaction-time— Spinal  Symptoms  (M.  J.  R.) — Deep  Reflexes- Tabetic  Gait 
(H.  U.)— Incontinence  and  Retention — Atrophy  of  Vesical  Muscle — The  Blood 
in  General  Paralysis. 

It  is  not  an  easy  task  for  the  student  to  gain  a  clear  and  compre- 
hensive view  of  so  protean  a  malady  as  that  of  general  paralysis  of  the 
insane ;  nor  need  he  be  surprised  or  discouraged  at  this  when  he  is 
informed  that  most  authoi'ities  on  the  subject  difter  as  to  supposed 
varieties  of  the  disease — whilst  others  are  sceptical  as  to  whether  the 
term  does  not  comprise  several  rather  than  one  pathological  entity. 
"When  he  is  further  told  that  no  single  portion  of  the  entire  cerebro- 
spinal system  and  its  peripheral  nerves  (not  even  the  sympathetic 
system  itself)  is  safe  from  the  encroachments  of  this  far-reaching 
disease,  he  will  be  prepared  to  meet  with  a  most  complex  sympto- 
matology, and  one  in  which  vai'ied  groupings  of  symptoms  may  present 
themselves  as  one  or  other  region  of  the  nervous  centres  is  implicated. 
Although  the  whole  cerebro-spinal  axis  may  become  involved  in  this 
disease,  it  yet  undoubtedly  expends  its  chief  force  upon  the  cei-ebral 
cortex,  which  is  primarily  the  affected  site ;  yet,  cerebral,  bulbar,  or 
spinal  symptoms  may  one  or  the  other  preponderate,  or  be  so  variously 
grouped  and  associated,  that  several  artificial  subdivisions  of  general 
paralysis  have  been  framed  by  different  French  writers  of  eminence, 
the  utility  of  which,  however,  is  questionable,  except  as  a  matter  of 


EGOISM EARLY  MORAL  PERVERSIOX.  251 

pure  convenience  for  purposes  of  description ;  they  do  not  represent 
genuine  pathological  varieties.  What  the  student  should  more 
especially  bear  in  mind  is  the  fact  that,  in  this  affection,  he  is 
dealing  with  a  coarse  brain  disease,  which,  implicating  primarily  the 
highest  nervous  arrangements,  is  prone  to  spread  progressively,  both 
laterally  and  in  depth ;  a  disease  which  ultimately  leads  in  all  cases 
to  dissolution  of  such  nervous  mechanism,  and  to  correlated  mental 
reductions.  The  progressive  impairuient  of  highly  elaborated  motor 
mechanisms  and  the  mental  reductions  comprise  the  characteristic 
features  of  this  disease,  however  diversified  in  type.  Moreover,  his 
anatomico-physiological  studies  of  the  brain  will  have  taught  him  that 
in  a  disease  spreading  over  the  sensory  and  motor  areas  of  the  cortex 
(involving  so  universally  the  substrata  of  the  mental  operations)  the 
mode  of  onset,  the  signs  and  symptoms,  the  progress  and  duration, 
will  vary  greatly  with  the  regions  first  implicated. 

ProdPOmal  Stag's. — The  prodromal  stage  of  general  paralysis  is  of 
very  variable  duration ;  it  is  usually  prolonged  over  many  months, 
and  often  embraces  a  period  of  several  years.  Many  of  the  symptoms 
then  apparent  are  trivial,  taken  by  themselves  ;  but  several  are  of  the 
gravest  import  and  highly  significant,  especially  when  the  ensemble  is 
considered.  A  restless,  unwonted  activity  (mental  and  physical)  is  of 
frequent  occurrence,  a  feeling  of  superabundant  energy  prevails,  for 
which  there  appears  no  adequate  relief;  often  there  is  undue  irritabil- 
ity and  a  perverseness  which  will  not  brook  control  or  contradiction — 
an  unreasonable  demand  upon  the  time  and  indulgence  of  others ; 
waywardness,  fickleness,  or  outbursts  of  furious  passion  upon  trivial 
pretexts  in  those  who  had  previously  been  more  self-controlled  and 
amiable ;  a  growing  change  in  the  disposition  and  character,  usually 
signalised  by  perversion  of  some  one  or  more  of  the  moral  sentiments 
— a  fact  of  primary  import  from  a  medico-legal  point  of  view. 

The  implication  of  the  aff'ective  sphere  of  mind  may  issue  in  melan- 
cholic gloom  or  despondency;  or,  on  the  other  hand,  in  undue  elation 
and  hien-etre ;  but  just  as  often  in  sudden  alternations  of  mood  fi'om 
one  extreme  to  the  other.  The  general  restlessness  spoken  of  pertains 
particularly  to  the  ordinary  pursuits  of  life  and  business;  there  is  undue 
eagerness,  a  planning,  scheming  spirit,  often  exhibited  in  extravagant 
investments  or  in  extraordinary  outlay  incommensurate  with  the  sub- 
ject's resoui'ces.  Or  it  may  show  itself  as  intense  anxiety  about  his 
prospects,  his  home  and  family.  This  frequently  passes  into  more 
marked  elation,  an  egoism  which  displays  an  exalted  view  of  his  own 
attainments  in  science,  in  art,  or  in  general  intellectual  capacity ;  an 
officious  self-gratulation ;  a  tendency  to  extravagant  talk,  to  laudation 
of  his  own  status,   his  wife  and  family,   and  a  yearning  to  test  his 


-';)-'  OENERAL    PAnALYSIS. 

intellectual  or  physical  vigour.  The  religious  sentiment  is  often  in 
the  ascendency,  and  may  lead  to  various  philanthropic  schemes ;  and 
new  projects  may  be  based  upon  similar  exaltation  of  the  domestic  or 
social  feelings.  Emotional  waves  are  of  frequent  occurrence ;  and 
silly,  uncontrollable  laughter  may  replace  passionate  weeping,  for  whicji 
no  adequate  cause  can  be  assigned.  It  will  be  observed  that  we  do 
not  infer  from  all  this  a  distinctly  dehuhd  state  of  mind — the  existence 
of  delusions  becomes  a  more  prominent  feature  in  the  subsequent 
stage — although  at  this  period  the  patient  hovers  on  the  borderland  of 
delusional  perversion.  The  judgment  is  enfeebled  and  clouded  (not 
necessarily  perverted),  and  the  condition  is,  in  fact,  one  of  over- 
balance. As  before  remarked,  moral  pervePSion  is  what  appears  so 
frequently  to  present  itself  at  this  period  of  incubation;  moral  lapses 
are  so  frequent  at  this  time  that  the  unfortunate  subject,  especially  if 
he  belong  to  the  lower  strata  of  society,  becomes  lodged  in  prison  and 
detained  for  offences  committed  during  this  early  period  of  alienation. 
It  is  a  most  common  experience  in  public  asylums  to  receiA'e  from 
prison  authorities  subjects  of  this  disease,  who  have  been  arrested  for 
theft,  drunkenness,  violence,  or  indecent  assault.  The  moral  lapses 
to  which  we  now  refer  differ  essentially  from  the  acts  of  those  suffer- 
ing from  so-called  moral  insanity.  In  the  latter,  the  actions  indicate 
impulsive  and  uncontrollable  states,  as  the  result  of  a  lowered  or 
defective  moral  sense ;  the  normal  inhibitory  control  is  wanting  and 
instinctive  impulses  rise  into  full  activity.  It  is  not  so  with  the 
acts  of  the  general  paralytic ;  they  are  neither  premeditated  nor 
impulsive,  but  casual,  often  appearing  to  be  unconsciously  performed  ; 
even  if  the  act  appear  determinate,  its  nature  and  consequences  are 
wholly  obscure  to  the  agent's  mind. 

And  here  the  essential  nature  of  these  acts  on  the  part  of  such 
subjects  becomes  apparent ;  that  high  degree  of  representativeness 
essential  for  the  recall  of  similar  actions  previously  performed,  and  the 
vivid  realisation  of  the  consequences  of  such  actions  in  the  past,  is  here 

icholly  loanting ;  and  still  less  is  that  re-representative  facility 

intact,  which  enables  him  to  contrast  the  act  as  ^•icwcd  in  its  nature 
with  certain  ethical  canons.  The  moral  lapse  is,  therefore,  truly 
significant  of  a  clouded  intellect,  of  an  incipient  dementia — the 
cognitive,  relational,  or  intellectual  element  of  mind  is  on  the  wane. 
That  such  acts  are  not  merely  the  result  of  simple  perversions  of 
the  moral  feeling  is  sufficiently  attested  to,  by  the  complete  absence 
of  forethought  and  judgment  which  characterises  them,  by  the  absence 
of  choice  of  circumstances  favouring  the  act,  by  the  want  of  object  or 
reasonable  motive — as  when  a  wealthy  man  purloins  an  article  of 
trivial  value,  as  well  as  by  the  silly  character  of  the  act  and  manner 


ENFEEBLED    ATTENTION — TRANSIENT    AMNESIA.  253 

of  its  accomplishment.  An  act  of  theft  may  be  comiiiittcd  with  open 
cfTrontery,  no  attempt  at  conceahnont  Ijoing  made ;  the  most  wanton 
outrage  on  public  decency — the  most  audacious  libertinism — may  be 
committed  by  an  individual  apparently  quite  oblivious  to  a  brcacli 
of  public  morals.  Thus,  a  respectable  member  of  society,  of  good 
social  standing,  gifted  with  many  amiable  virtues  and  natural  talents, 
suddenly  develops  an  unusual  and  objectionable  freedom  of  speech  and 
action,  shocks  his  wife  and  family  by  various  irregularities ;  plays  the 
"hero  to  the  barmaid;"  indulges  in  unwonted  alcoholic  excesses;  makes 
extravagant  purchases  or  silly  presents  to  quondam  friends  and  casual 
acquaintances,  for  whom  he  suddenly  professes  a  sincere  attachment. 
In  one  such  case,  observed  by  the  writer,  extreme  emotional  instability 
prevailed,  violent  passion  would  ensue  upon  the  most  trivial  occur- 
rence, and  just  as  readily  might  the  patient  be  calmed  into  good 
humour,  or  made  to  shed  tears  profusely.  Another  patient,  watched 
through  this  stage  of  the  disease,  conceived  exalted  notions  respecting 
his  family ;  his  eldest  daughter  became  a  constant  theme  of  converse, 
on  which  he  would  fondly  dwell  until  he  had  utterly  wearied  his 
hearers.  He  then  developed  a  too  amiable  weakness  for  the  other  sex, 
and  from  being  a  model  husband,  became  careless,  suddenly  left  his 
home,  and  was  not  heard  of  for  some  weeks.  It  then  appeared  he  had 
developed  a  craze  for  preaching,  and  had  travelled  as  an  itinerant 
preacher  amongst  the  mining  community  of  South  Wales.  He  re- 
turned to  his  friends  deeply  impressed  with  the  importance  of  his 
mission;  talked  incessantly  upon  religious  topics;  and  became  morbidly 
depressed  and  hypochondriacal.  In  a  case  of  incipient  general  paralysis, 
the  subject  of  which  was  a  highly  talented  mathematician,  one  of  the 
earliest  psychical  symptoms  was  intense  despondency,  together  with 
sudden  lapse  of  attention  and  memory.  Often  when  absorbed  in  the 
interest  of  solving  a  problem  have  we  seen  him  cover  his  face  with  his 
hands;  rise  from  his  chair;  and  with  a  pained  expression  and  the 
hurried  remark,  "  It's  of  no  use — it's  all  gone,"  hurriedly  leave  the 
room.  He  frequently  confessed  how  painful  such  a  state  was  to  him  ; 
how  utterly  incapable  he  felt  of  exercising  the  slightest  eftort  of  atten- 
tion ;  and  how  completely  oblivious  he  became  to  the  various  links 
of  the  argument  followed,  before  this  disruption  occurred.  In  this 
instance  these  sudden  amnesic  attacks  prevailed  for  many  months 
before  definite  aberration  was  recognised,  and  the  onset  of  the  estab- 
lished disease  was  one  of  sudden  maniacal  excitement,  accompanied  by 
acute  hallucinations.  This  subject  also  spoke  to  his  medical  friends  of 
the  sudden  and  causeless  emotional  states — "as  a  welling-up  of  his 
feelings,  only  relieved  by  a  passionate  flood  of  tears." 

The  transitory  amnesic   states  are  very  frequent  as  an   early 


25-t  GENERAL    PARALYSIS. 

symptom  of  the  disease,  and  almost  invarialily  imply  a  serious  failure 
in  attention — the  faculty  which,  as  Sir  Crichton-Jirownc  has  insisted, 
is  earlier  impaired  than  any  other.  To  the  same  origin  must  be 
attributed  the  furr/e.tj'ulness  which  is  an  invariable  accompaniment 
of  this  early  stage,  and  which  so  often  leads  to  inconsistent,  ludicrous 
conduct;  inattention  to  the  claims  of  others  ;  and  unconscious  infringe- 
ment of  codes  of  honour,  or  of  courtesy, 

' '  This  loss  of  memory  will  be  observable  in  many  ways  ;  especially  is  he  likely 
to  forget  what  he  has  done  a  day  or  two  previously ;  and  he  will  not  only  be 
forgetful,  he  will  be  careless,  apathetic,  and  indifferent  about  that  which  formerly 
interested  him ;  and,  when  he  takes  up  new  schemes  and  projects,  his  attention 
soon  flags,  and  his  interest  vanishes.  We  see,  in  short,  in  his  whole  mamier  of 
life  a  weakening  of  mind,  such  as  may  be  noticed  in  the  commencement  of  senile 
dementia ;  but  which,  occurring  in  a  fine  and  vigorous  man  of,  it  may  be,  thirty- 
live,  too  surely  indicates  the  ruin  even  now  commencmg"  {Bland/ord).* 

We  observe,  at  this  pei'iod,  that  a  very  impressionable  state  of 
the  vaso-motor  system  often  prevails;  palpitation  with  alternating 
flushing  and  pallor  of  the  face,  or,  often,  severe  headache  and  neuralgic 
pains  are  complained  of;  the  circulation  is  generally  sluggish;  and  an 
early  symptom  (one  for  wdiicli  the  patient '  often  first  comes  under 
notice)  is  that  of  a  torpid  liver.  The  hepatic  functions  are  almost 
invariably  deranged,  leading  to  obstinate  constipation,  bulimia,  and 
digestive  troubles;  the  skin  often  assumes  an  icteric  tinge;  such  symp- 
toms affording  material  for  hypochondriacal  complaints ;  numbness 
of  the  hands,  with  tingling  and  formication  of  the  skin,  are  also  not  in- 
frequently complained  of.  Another  frequent  premonition  is  that  of 
A-ertiginous  attacks ;  slight  attacks  of  vertigo  often  escape  notice,  the 
patient  not  complaining  unless  his  attention  is  directed  to  the  matter; 
they  occasionally,  however,  become  severe. 

Even  at  this  early  date  there  may  appear  distinct  motor  troubles, 
a  fine  fibrillary  quivering  of  the  tongue  may  be  observed,  or  a  coarser 
twitching  of  individual  fibres ;  an  inco-ordinate  jerky  protrusion  of 
the  organ ;  a  tremulousness  of  the  upper  lip  or  the  facial  muscles 
during  conversation.  Pupillary  anomalies  may  coexist  also,  or  may 
antedate  the  above  paretic  symptoms  by  months  or  even  years,  as 
aflSrmed  by  Griesinger.  Another  highly  significant  group  of  .symp- 
toms is  constituted  by  certain  epileptiform  or  apoplectiform  seizures 
which  may  now  ensue,  and  which  may  become  frequent  at  a  later 
stage  of  the  disease.  They  may  usher  in  the  fully-established  affection, 
and  thus  may  form,  so  to  speak,  a  definite  line  of  demarcation  between 
the  earlier  and  the  second  stage;  but  it  is  just  as  frequent  to  hear  of 
such   seizures,   both   convulsive    and    apoplectiform,   far   back    in   the 

history  of  the  case. 

*  Op.  cit.,  p.  2G0. 


ESSENTIAL    NATURE    OF    THE    DELUSIONS.  255 

Second  Stag's. — After  this  stage  of  alienation  has  prevailed,  for  a 
longer  or  shorter  period,  more  active  symptoms  are  liable  to  arise  ; 
it  may  be  by  a  gradual  transition;  but,  often,  there  is  an  abrupt 
passage  into  a  maniacal  condition  in  which  vivid  hallucinations  pre- 
vail. The  intensity  of  the  excitement  is  often  extreme,  acute 
maniacal  states  (verging  even  upon  delirious  mania)  are  frequent  j 
incessant  restlessness,  obstinate  sleeplessness,  noisy  boisterous  excite- 
ment, and  blind  uncalculating  violence,  especially  characterise  such 
states.  The  reductions  are  so  great  that  the  subject  wholly  fails  to 
appreciate  the  meaning  of  the  simplest  assistance  rendered  him  ;  he 
struggles  violently,  and  resists  attempts  to  dress  or  undress  him,  or 
to  give  him  the  necessary  food.  His  violence  is  often  so  great  as  to 
expose  him  to  the  most  serious  risk  of  fractured  bones,  even  from 
the  best  directed  efforts  to  nurse  and  nourish  him  ;  such  cases  are  a 
source  of  the  greatest  anxiety  in  our  asylums.  The  blind  fury  of 
these  states  remind  us  of  similar  states  of  excitement  in  the  epileptic; 
and,  as  a  fact,  are  frequently  a  sequence  of  epileptiform  seizures  or  of 
attacks  simulating  petit  mal.  In  the  less  acute  maniacal  attacks  the 
characteristic  delusional  state  of  mind  reveals  itself.  With  beaming 
face  and  muscles,  tremulous  from  emotions,  he  endeavours  to  fix  the 
glorious  but  transient  visions  which  float  before  his  mind's  eye;  in 
rambling  incoherent  utterances  he  insists  upon  his  wealth,  his  exalted 
station  or  future  destiny. 

It  will  repay  us  to  study  a  little  more  closely  the  nature  of  this, 
expansive  delirium.  In  the  first  place  the  delusional  state  is  the 
antithesis  of  the  so-called  monomaniacal  delusion,  which  is  essentially 
fixed  in  character,  and  is  in  itself  a  direct  perversion  of  the  individual's 
intellectual  life.  The  grandiose  conceptions  of  the  general  paralytic 
ai"e  wholly  difierent  in  their  nature,  and  are  the  direct  outcome  of 
an  unrestrained  imaginative  faculty,  no  longer  subject  to  the  coercion 
of  the  reason.  Those  standards  of  objective  reality  which  a  life-long 
experience  and  knowledge  may  have  established,  no  longer  exist  for 
him,  or  are  clouded  by  the  mental  storm ;  and  the  only  criteria  of 
truth  perceived  are  the  subjective  impressions  aroused  by  the  morbid 
excitation  of  his  imaginative  sphere  of  life  ;  there  is  no  reason  why  he 
should  doubt  their  reality,  as  no  challenge  can  be  giA'^en  by  the  over- 
clouded reason,  and  so  the  sensuous  procession  of  impressions  pass  by 
in  cverchanging  kaleidoscopic  hues,  uniting  and  reuniting  in  fantastic 
combinations,  conjuring  up  visions  of  immortal  life,  of  love,  of  beautyj 
of  wealth,  or  of  honour,  or  of  all  that  mortal  could  desire.  Challenge 
him  iipon  the  absurdity  of  his  statements  and  a  momentary  irritation 
may  occur;  but  he  readily  wanders  off" into  his  grandiose  strain,  asserting 
and  reasserting  with  stronger  emphasis  still  more  extravagant  delusions. 


•256  r.EXERAL    PARALYSIS. 

It  is  in  these  states  that  the  enfeeblement  of  attention,  is  pre- 
eminently noticeable ;  faulty  it  was  in  the  earlier  stage,  as  we  saw  in 
the  resulting  nmeraonic  lapses  and  amnesic  states ;  but,  its  failure 
now  is  a  far  more  serious  matter.  The  contrasting  faculty  of  the 
mind,  whereby  a  rational  judgment  can  be  formed,  must  decline  with 
this  enfeebled  attention,  since  it  depends  for  its  existence  upon  the 
vigour  of  the  latter.  This  failure  of  attention  can  be  occasionally 
elicited  in  a  remarkable  manner  as  regards  certain  special  mental 
operations.  It  is  readily  observed  upon  testing  this  faculty  that  it 
occasionally  fails  more  with  certain  mental  operations  than  with 
others — naturally  with  those  less  habitual  to  the  subject — and,  if  we 
continue  to  test  the  patient  in  this  direction,  the  strain  becomes 
at  times  intolerable,  and  has  a  strange  result.  Thus  in  a  patient, 
who  was  garrulous  and  optimistic,  talking  incessantly  upon  the 
subject  of  his  "  coursers  and  blood-horses,"  it  was  detected  that  he 
could  not  direct  his  attention  to  simple  numerical  calculations  without 
much  painful  effort ;  upon  one  occasion,  therefore,  when  his  attention 
was  forcibly  directed  towards  a  simple  sum  of  addition,  after  giving  a 
wrong  answer  once  or  twice,  the  effort  resulted  in  a  sudden  (but 
transient)  loss  of  consciousness,  a  twitching  of  the  facial  muscles  and 
rio-ht  hand,  and  an  aphasic  state  lasting  some  five  minutes  after 
re"-aining  consciousness.  The  following  day  a  similar  test  was  applied 
to  this  patient  with  identical  results,  except  that  the  convulsive  dis- 
charge was  spread  over  a  wider  range. 

Beyond  the  fact  that  the  delusions  of  the  general  paralytic  are  so 
transient  and  variable,  there  is  their  simple,  sensuous  and  fragmentary 
nature  to  be  noted ;  they  bear  no  logical  connection  the  one  to  the 
other,  and  are  therefore  most  incongruous  and  self-contradictory. 
Then,  again,  such  delusions  are  simple  assertions,  the  general  paralytic 
does  not  reason  out  his  delusive  concepts,  or  attempt  to  erect  a  system 
of  belief  thereupon ;  he  simply  asserts,  reasserts,  and  never  attempts 
a  proof.  Herein  again  we  see  the  distinction  between  his  delusions  and 
those  of  the  monomaniac.  In  normal  states  the  imaginative  faculty, 
however  active,  if  duly  controlled  by  reason,  may  find  its  expression 
in  poetic  imagery  or  on  the  painter's  canvas ;  but  in  the  case  of 
general  paralysis,  emancipated  from  such  guidance,  its  vagaries  become 
so  astounding  that  they  defy  expression.  We  all  know  how  the  very 
indetiniteness  of  emotional  states  renders  their  expression  by  language 
difticult,  and  at  times  impossible ;  and  how,  in  contrast  with  the 
feelings,  the  subjects  of  exact  knowledge  find  a  ready  medium  for 
their  expression  and  elucidation  in  the  faculty  of  speech.  The 
mental  life  of  the  general  paralytic  at  this  stage  is  so  far  made  up 
of  sensuous  feelings  and  their  residual  emotions,  that  he  wholly  fails 


DELIRIOUS   CONCEPTIONS — FACIAL   STOLIDITY.  257 

to  his  own  satisfaction,  to  express  by  language  what  rises  before  his 
mind,  liis  feeling  and  mental  imagery  are  illimitable,  and  submit  not 
to  the  definition  of  words.  Thus,  in  each  repeated  utterance,  he  tries 
to  rival  his  former  extravagance ;  he  has  not  simply  millions,  but 
"thousands  of  millions  of  millions  of  millions." 

The  nature  of  our  patient's  occupation,  and  the  subjects  which  have 
chiefly  engrossed  his  mind,  will  usually  afford  material  for  these  delirious 
conceptions ;  thus,  a  poor  labourer  who  through  years  of  anxious  toil 
has  struggled  to  support  a  large  family  believes  that  he  has  accumulated 
enormous  wealth  —  "is  heir  to  extensive  domains,  and  his  children 
princes  of  royal  blood ; "  another,  a  schoolmaster,  talks  on  schemes  of 
universal  education.  One  who  had  squandered  his  means  upon  the 
turf  was  the  imagined  possessor  of  twenty  hunters  which  he  had  just 
sold  for  £350  each;  another,  a  poor  carter,  is  possessed  of  a  magnificent 
team  of  horses,  each  of  which  he  calls  by  name,  and  excitedly  smacks 
an  imaginary  whip,  as  he  drives  them  on  in  mad  career.  One  who 
had  occupied  a  foreign  diplomatic  post  had  conceived  extraordinary 
schemes  for  developing  the  industrial  and  mercantile  resources  of  all 
the  European  nationalities.  Some  are  agitated  by  vast  philanthropic 
schemes ;  one  of  our  patients  was  going  to  empty  all  the  prisons, 
asylums,  and  workhouses  in  England,  and  start  each  individual  afresh 
in  life  "  upon  a  sovereign  each ; "  another  intended  paying  off  the 
National  debt.  The  exuberant  welling-up  of  feeling  transforms  the 
status  and  surroundings  of  the  subject  without  affecting  his  real 
identity ;  he  still  retains  his  name,  but  is  now  a  duke,  a  king,  or 
emperor ;  his  wife  and  children  still  are  his,  but  are  exalted  into 
corresponding  dignities  ;  whilst  the  asylum  is  a  gorgeous  palace,  the 
nurses  or  attendants  transformed  into  princes  or  courtiers. 

Fantastic  decoration  is  much  indulged  in,  especially  by  the  female 
paralytic ;  scraps  of  coloured  stuffs,  ribbons,  and  coloured  paper  are 
stitched  on  to  their  clothing  as  insignia  of  distinction,  or  as  an 
addition  to  the  attractiveness  of  the  subject.  The  sexual  charac- 
teristics are  prominently  developed ;  the  female,  especially,  betraying 
much  personal  vanity  or  much  self-consciousness  in  the  presence  of 
the  opposite  sex ;  she  is  often  engaged  on  matrimonial  alliance  ; 
connubial  subjects  occupy  the  chief  theme  of  her  delusions ;  and, 
occasionally,  a  well-marked  erotic  state  prevails.  On  the  other  hand, 
the  male  paralytic  raves  upon  wealth,  property,  social  position,  pro- 
fessional attainments,  manual  dexterity,  artistic  ability,  muscular 
power,  and  endurance.  The  variety  and  transient  nature  of  these 
delusions  ;  their  utter  silliness,  impossibility,  and  inconsistencies,  in- 
dicate a  serious  degree  of  dementia  in  which  an  enfeebled  attention 
and  an  unbounded  license  of  the  imaginative  faculties  coexist.     The 

17 


258  GENERAL    PARALYSIS. 

associated  excitement  may  at  times  be  in  abeyance,  to  be  called  up 
readily  upon  the  slightest  reference  to  optimistic  or  grandiose  sub- 
jects, when  the  stolid,  half-vacant  impression  lightens  up  into  a  look 
of  fatuous  rapture  as  he  pours  out  his  delirious  notions.  Even  in 
the  calmest  moments  an  undercurrent  of  excitement  usually  exists, 
especially  manifested  in  restless,  purposeless  movements  and  mis- 
directed energy,  with  nocturnal  exacerbations,  during  which  he  is 
noisy,  destructive  of  clothing  and  bedding,  and  dirty  in  his  habits. 

It  is  at  this  stage  of  our  enquiry  that  two  groups  of  physical  signs 
become  prominent  features ;  present  as  they  may  be  in  the  earliest 
stage  of  the  disease,  they  are,  however,  almost  invariably  found  at 
this  period.  They  consist  in  certain  articulatory  troubles  and  oculo- 
motor paralysis.  Grandiose  delusions  with  maniacal  outbursts,  a 
delire  ambitieux,  are  by  no  means  an  unusual  feature  in  some  other 
forms  of  insanity;  but  when  to  this  delirium  there  is  superadded  a 
tremulousness  of  the  lips,  an  inco-ordinate  ataxic  state  of  the  tongue, 
and  certain  pupillary  anomalies,  the  diagnosis  of  general  paralysis 
is  next  to  conclusive.  The  facial  expression  of  the  general  paralytic 
is  characteristic ;  when  unmoved  by  emotional  excitation  there  is 
great  stolidity,  with  a  somewhat  vacant  demented  aspect,  but  when 
roused  into  conversation  the  face  beams  with  emotional  excitement, 
the  lips  and  facial  muscles  become  tremulous,  and  twitchings  of  the 
muscles  of  the  brow  are  noticeable.  The  tremulousness  of  the  lips 
is  well  compared  by  Dr.  Bucknill  to  the  like  tremulousness  in  a 
person  about  to  burst  into  a  flood  of  tears.  An  uneasy  fixity  of  the 
lips  is  noticed  in  some,  and  a  tendency  to  place  the  hand  over  the 
mouth  whilst  speaking,  in  full  consciousness  of  the  failure.  When 
the  tongue  is  protruded,  it  is  with  ataxic  jerks  or  irregular  inco- 
ordinate movements ;  and  a  fine  fibrillar  tremor  will  be  perceptible 
whilst  it  is  extended.  In  advanced  cases  the  tongue  will  be  protruded 
only  with  great  effort,  the  mouth  being  widely  opened,  the  eyes 
staring,  and  the  whole  head  trembling  and  unsteady  with  the  effort 
expended.     The  articulation  is  now  distinctly  impaired. 

Articulatory  Troubles. — The  character  of  the  articulation  is 
distinctive;  it  is  slowed,  hesitating,  blurred,  approaching  that  of  a 
drunken  man ;  its  utterance  is  broken,  syllaT)ic  recurrences  are  inter- 
polated, and  the  difficult  enunciation  may  end  in  an  explosive  effort. 
In  the  early  stages  of  the  disease,  however,  a  slow,  laboured  enuncia- 
tion, with  slight  blurring  of  consonantal  sounds,  may  be  all  that  is 
recognisable ;  but,  upon  excited  converse,  as  when  rallied  on  the 
subject  of  his  delusions,  the  impairment  may  be  at  once  exaggerated 
and  accompanied  by  the  characteristic  treinor  of  the  upper  lip.  It  is 
the  labial  and  lingual  utterance  which  suffers  chiefly;  and,  if  present. 


ARTICULATORY    TROUBLES — CEREBRAL    SEIZURES.  259 

it  is  at  onco  manifested  by  requesting  liiui  to  repeat  any  alliterative 
doggrel;  to  repeat  distinctly  such  words  as  hippopotamus  or  peram- 
bulator. The  paralysis  of  lips  and  tongue  advances  in  later  stages 
to  a  more  profound  degree,  and  attempts  at  speech  issue  in  an 
inarticulate  muttering  of  broken  unintelligible  jargon,  in  which  here 
and  there  some  woi'd  is  recognised. 

"Cerebral  Seizures."  —  During  this  stage,  or  later  still,  the 
patient  may  be  subject  to  convulsive,  apoplectic,  or  paralytic  seizures ; 
and  very  few  indeed  pass  through  the  descending  series  of  dissolutions 
of  general  paralysis  without  suffering  from  one  or  more  of  these 
accompaniments.     Such  "seizures"  are — 

Syncopal  or  quasi-syncopal  attacks.  Epileptiform  discharges. 

Petit  mal,  or,  exceptionally,  grand  Apoplectiform  (or  true  congestive), 

mal.  attacks. 

Limited  (or  unilateral)  twitching.  Hemiplegiae  and  inonoplegise. 

Syncopal  Attacks. — These  are  by  no  means  infrequent  during 
the  progress  of  general  paralysis,  and  are  often  the  first  warnings  • 
given  of  a  failing  heart,  and  of  the  necessity  for  keeping  the  patient 
in  bed.  Thus  a  patient  taking  his  customary  meal  will  suddenly  turn 
pale  and  fall  forwards ;  his  pupils  are  dilated,  his  pulse  imperceptible, 
and  the  skin  cold  and  damp ;  no  convulsive  twitching  occurs,  and 
after  a  momentaiy  prostration,  he  rallies  and  recovers  his  former 
state.  Such  patients  demand  rest  in  bed.  Attacks  of  jjeiti  mal 
are  occasionally  mistaken  for  syncopal  attacks,  and  reported  as  slight 
*'  faints  "  by  the  nurse  or  friends. 

Epileptic  Seizures. — These  are  of  frequent  occurrence,  yet  by  no 
means  so  frequent  as  the  epileptiform  and  limited  convulsive  attacks. 
They  also  occur  in  early  stages  of  the  disease,  and  are  usually  referred 
to  by  the  friends  of  the  patient  as  slight  faints.  Attacks  of  the 
nature  of  j^^tit  mal  are  the  more  usual.  They  are  characterised  by  very 
transient  loss  of  consciousness  preceded  by  pallor,  wide  dilatation  or 
pupils,  and  perhaps  a  slight  twitching  of  one  side  of  the  mouthy 
followed  Ijy  much  confusion  of  thought,  obvious  in  inconsistent  speech, 
and  conduct ;  or  by  more  prolonged  automatic  states. 

J.  F.,  March  21,  18S1,  seized  this  morning  with  convulsions,  which  occur  every 
ten  or  fifteen  minutes,  and  are  identical  with  epileptic  seizures,  except  that  the 
convulsions  are  chiefly  unilateral,  involve  the  chest  muscles  but  slightly,  there 
being  also  no  lividity  of  face  nor  obstructed  breathing ;  each  attack  hists  for 
thirty  seconds  or  thereabouts. 

The  convulsive  phenomena  in  their  sequent  stages  were  as  follows  : — 
1.  No  pallor,  but  head  and  eyes  deviate  to  the  right ;  there  is  a  broken  inarti- 
culate cry  ;  the  pupils  dilate  widely ;  the  brow  is  raised  by  the  occipito-frontalis. 


260  GENERAL    PARALYSIS. 

2.  The  mouth  is  drawn  to  the  right,  lips  twitcli  strongly  and  uncover  the 
canines. 

3.  Riglit  arm  flexed,  with  forefinger  extended  ;  then  raised  and  convulsively 
jerked  at  shoulder  ;  tiie  brow  twitelies  violently. 

4.  In  certain  seizures  the  discharge  spread  to  the  right  leg  also,  but  did  not 
involve  the  left. 

After  the  fit  there  was  paralytic  deviation  of  head  and  eyes  to  the  left  and 
notable  helplessness  of  the  right  arm  ;  the  left  pupil  was  much  larger  than  the 
right,  but  slowly  regained  its  former  size  ;  there  were  champing  movements  of 
the  jaw  ;  no  exaggeration  of  patella-reflex  ;  no  ankle-clonos  ;  at  the  onset  of  each 
attack  the  heart,  previously  beating  strongly,  became  imperceptible  during  the 
tonic  stage.     The  cry  always  precedes  each  attack. 

Limited  or  Unilateral  Twitching". — Sudden,  rhythmic  twitching 

of  the  muscles  about  the  mouth,  or  of  the  specialised  groups  of  the 
hand,  or  of  the  forefinger  and  thumb  of  one  side  are  very  frequent, 
either  alone  or  in  combination ;  or  convulsive  twitching  of  the  flexors 
of  the  wrist  or  elbow  may  also  be  associated  therewith.  The  various 
muscles  of  the  thigh  or  leg  may  be  observed  picked-out  by  the  con- 
vulsive discharge,  or  the  whole  arm  or  leg  jerked  spasmodically. 
Siich  twitching  is  often  increased  by  handling  and  passive  movement 
of  the  limb.  The  limb  may  be  fixed  in  rigid  extension,  whilst  the 
toes  or  fingers  are  flexed  by  clonic  movements.  The  muscular  twitch- 
ing may  be  very  general,  involving  both  sides  of  the  body  (although 
unequally) ;  and  its  duration  may  be  protracted  over  days  or  even 
weeks  without  interruption.     The  following  case  illustrates  this  fact: — 

J.  S.,  a  general  paralj'tic,  was  seized  with  convulsive  twitchings  of  the  limbs  on 
the  25th  of  November,  18S6.  His  face  was  flushed  and  the  skin  covered  with  a 
greasy  unctuous  sweat.  Both  arms,  but  especially  the  left,  are  continually  and 
consentaneously  jerked  by  the  convulsive  twitching  of  the  extensor  group  for  the 
elbow  and  wrist,  the  fingers  of  the  left  hand  are  suddenly  spread  as  in  the  act  of 
playing  the  pianoforte  ;  the  toes  also  show  a  tendency  to  "spread,"  the  feet  being 
rigidly  extended,  whilst  there  is  almost  continuous  clones  of  both  ankles,  especially 
increased  by  flexion  of  the  foot ;  if,  during  a  period  of  partial  cessation  of  this 
clonic  state,  the  sole  be  irritated  by  a  pin,  clonos  is  again  briskly  established. 
There  is  a  notable  degree  of  the  "paradoxical  contraction."  The  superficial 
abdominal  reflexes  are  dulled.  Tache  cerehrah  is  rapidly  produced,  and  is  vivid 
over  all  parts  of  the  body.  Both  conjunctivre  are  injected  ;  both  pupils  show 
mydriasis,  but  the  left  is  larger,  and  both  are  fi^ed  to  a  bright  beam  of  light. 
Bowels  and  bladder  paralysed.     Patient  is  greatly  demented  and  quite  7nute. 

The  following  day  the  twitching  was  limited  to  the  left  foot  and  hand;  the  same 
expansive  movements  of  the  digits  occurring. 

November  30,  1886. — -The  convulsive  twitching  of  the  left  hand  and  foot 
remains  unchauged  ;  the  plantar  reflex  is  greatly  exaggerated  and  hj-per-sensitive. 

April  16,  1S87. — The  movements  above  described  have  continued  up  to  this 
date  (nearly  five  months)  without  interruption,  but  are  now  gradually  declining. 

The  above  was  of  course  an  instance  of  such  ccfevulsive  movements 


VARIED    CONVULSIVE    AFFECTIONS.  261 

ill  an  advanced  stage ;  but  similar  seizures  may  occur  at  a  very  early 
period  of  the  disease.  The  convulsive  twitching  is  usually  associated 
■with  a  certain  degree  of  reduction  in  consciousness ;  and,  when  the 
discharge  involves  the  right  side  of  the  face  and  hand,  aphasic 
states  may  prevail,  and  a  certain  degi-ee  of  WOrd-blindness  or 
deafness  presents  itself. 

EpileptifOPm  Seizures. — Under  this  term  are  comprised  general 
convulsive  seizures,  or  convulsive  discharges  fx'om  motor  centres, 
representing  large  associated  groups  of  the  musculature  of  the  body 
and  limljs.  Such  attacks  are  often  ushered  in  by  premonitory  twitch- 
ings,  such  as  those  just  described ;  they  ai-e  not,  as  a  rule,  accompanied 
by  complete  loss  of  consciousness.  The  convulsion  or  spasm  may 
start,  as  indicated  by  Mickle,  "  from  some  point  as  it  were,  becoming 
widely  spread  and  severe,  then  ebbs  away  and  ceases  evei-ywhere 
except  at  the  starting  point,  usually  the  mouth,  eye,  or  hand,  where 
occasional  jerks  are  seen  which  may  gradually  die  out ;  or,  on  the 
conti'ary,  the  preceding  cycle  of  events  may  be  repeated,  or  the  renewed 
convulsion  may  chiefly  affect  the  other  side."  * 

The  onset  of  the  attack  is  almost  invariably  hemispheric — i.e.,  the 
convulsions  begin  unilaterally,  and  may  or  may  not  spread  to  the 
opposite  side ;  they  are  often  preceded  by  a  well-marked  tonic  stage 
as  the  rapid  pi'imary  discharges  occur;  the  clonic  stage  being  often 
long  jjroti-acted,  becoming  more  and  more  broken-up  into  intervals  of 
comparative  rest  until  at  last  an  occasional  convulsive  jerk  of  the 
limb  or  separate  muscular  contractions  alone  prevail. 

Another  form  occasionally  met  with  is  that  of  an  associated  move- 
ment of  the  head  and  arm  ;  the  head  and  eyes  turn  as  if  looking  over 
the  shoulder,  the  pupils  dilate  widely,  and  the  arm  of  this  side  is 
simultaneously  raised  in  the  same  direction  with  the  forefinger  ex- 
tended, and  a  painful  cry  escapes  tlie  patient.  This  movement  may 
be  repeated  over  and  over  again  for  hours  in  succession.  It  is 
important  to  recognise  this  form  as  occasional  in  general  paralysis 
since  it  has  been  afiirmed  that  the  cry  is  a  distinctive  feature,  thus  : — 
"Patients  in  the  fits  of  general  paralysis  seldom  bite  the  tongue,  the 
convulsions  are  not  so  violent,  there  is  not  the  aura,  nor  the  cry,  and 
the  mental  symptoms  will  of  coui'se  be  quite  different."  f  (Blandford). 

These  convulsive  attacks  will  be  followed  by  the  usual  results 
observed  after  severe  discharges  from  cortical  grey  matter.  There  will 
be  partial,  or  more  or  less  complete,  paralysis  of  the  muscles  involved; 
the  facial  muscles  may  be  involved,  the  cheek  flattened,  and  the 
mouth  drawn  to  the  opposite  side ;  there  may  be  more  or  less  g'loSSO- 

*   Treatise  on  General  Paralysis,  p.  163. 
t  Op.  cit.,  p.  266  (Italics  not  in  original). 


262  GENERAL    PARALYSIS. 

pleg'ia,  or  the  patient  may  be  completely  aphaslc  with  right  brachial 
monopleg'ia ;  or  the  log  only  may  bo  tomporarily  paralysed,  or 
hemiplegia  may  prevail.  Conjug'ate  deviation  of  the  head  and  eyes 
is  also  frequent  as  a  })Ost-convulsive  sign. 

Epileptiform  seizures  may  occur  at  an  early  period  of  the  disease, 
usually  not  until  twelve  months  have  elapsed.  According  to  Dr. 
Newcoml)e,  out  of  100  general  paralytics,  51  patients  suffered  from 
epileptiform  seizures,  and  of  these  51,  as  many  as  19  did  not  develop 
such  symptoms  until  between  twelve  to  twonty-fuur  months  after  the 
commencement  of  the  disease,  whilst  one  only  had  convulsions  within 
three  months  of  the  onset.* 

The  immediate  result  of  these  general,  wide-spread,  epileptiform 
convulsions  is  of  far  greater  import  as  affecting  the  mental  aspect  of 
oiir  patient.  They  usher  in  the  gravest  reductions,  often  leaving  the 
subject  a  complete  mental  wreck.     Take  for  instance  the  case  of 

H.  P.,  who  was  in  the  second  stage  of  general  paralysis,  was  mildly  excited, 
and  the  subject  of  extravagant,  grandiose  notions,  yet  retaining  a  fair  amount  of 
mental  energy  sufficient  to  enable  him  to  read,  write,  or  to  converse  in  a  connected 
strain  of  thought,  so  long  as  his  delusional  ideas  were  not  entrenched  upon.  He  was 
suddenly  seized  with  epileptiform  convulsions,  commencing  on  the  left  side  of  the 
body,  but  usually  spreading  to  the  opposite  side ;  such  seizures  occurring  several 
times  in  the  course  of  the  day  and  night,  and  lasting  for  several  days  together.  On 
their  cessation  he  was  left  in  a  condition  of  profound  imbecility,  from  which  he 
never  rallied.  In  his  case,  persistent  and  copious  watery  alvine  evacuations 
accompanied  tlie  convulsive  attacks. 

The  mental  deterioration  following  epileptiform  seizures  is  often  so 
notable  as  to  sharj)ly  demarcate  the  stage  of  maniacal  excitement  and 
delusional  perversion  from  the  last  stage  of  hopeless  dementia  and 
motor  helplessness. 

The  epileptiform  seizui*e  is  also  ominous  of  rapid  break-down ;  "  in 
twenty-four  out  of  sixty  cases,  death  occurred  within  a  month  after  an 
attack"  {N/'wcomb'').j 

Apoplectiform  Seizures. — The  patient  may  be  struck  down 
suddenly  by  symptoms  of  an  apoplectic  type,  associated  occasionally, 
but  by  no  means  necessarily,  with  slight  convulsive  discharge.  He 
becomes  helpless  in  his  limbs,  heavy,  lethargic,  and  stupid,  and  this 
state  may  deepen  into  complete  coma.  The  face  is  deeply  flushed, 
the  head  hot,  and  the  body  generally  bedewed  Avith  perspiration  ; 
the  breathing  may  be  heavy  and  laboured,  the  jnilse  rapid,  and  the 
temperature  quickly  rises  to  103°  or  higher.     The  condition  is  always 

*  See   "Epileptiform  seizures  in  general  paralysis  of  the  insane,"   Went  Iiidinj 
Asylum  Reports,  vol.  v. 
t  Loc.  cit. 


PARALYTIC   SEIZURES — REACTION-TIME    IN   GENERAL    PARALYSIS.     2G3 

a  critical  one,  there  being  hypostatic  engorgement  of  the  lungs  and 
pneumonia  threatening  the  patient's  life;  if  this  is  not  fatal,  it  is 
always  followed  by  serious  results — viz.,  by  various  motor  paralyses, 
the  advance  of  dysphag'ic  symptoms,  and  by  much  increased  mental 
enfecblement. 

Monoplegiae  and  Hemiplegise. — Paralysis  suddenly  occurring 
without  apoplectic  or  epileptic  premonitions  involving  one  or  both 
limbs,  or  complete  hemiplegia,  of  very  transient  duration,  is  another 
feature  frequ.ently  occurring  in  the  course  of  this  disease.  The  sudden- 
ness of  onset  is  notable  ;  the  hand  drops  whilst  at  work  utterly  helpless; 
or  the  patient  suddenly  stumbles  whilst  walking,  and  is  found  paralysed 
in  one  leg ;  the  deep  reflexes  will  be  exaggerated  and  ankle-clonos 
prevail.  Patients  will  thus  be  found  after  a  quiet  night's  rest  suffering 
from  a  CPUPal  or  a  brachial  monoplegia  which  may  have  com- 
pletely disappeared  in  a  few  hours  or  days. 

Reaction-Time. — A  large  proportion  of  paralytic  subjects  are 
necessarily  excluded  from  attempts  at  estimating  the  rapidity  of 
reaction  to  the  stimuli  of  light  and  sound ;  it  is  only  in  the  earlier 
stage  of  the  disease,  ere  the  patient  has  succumbed  to  any  notable 
degree  of  dementia,  that  a  reliable  record  is  obtainable.  Such  results, 
however,  have  been  secured  in  the  accompanying  series  of  patients, 
special  care  having  been  exercised  to  exclude  any  source  of  fallacy,  the 
result  being  accepted  only  after  repeated  observations,  and  each  record 
being  the  average  of  twenty  trials. 


Reaction-Time  in  General  Paralysis. 


T.  P.,  .  Maniacal,  garrulous,  egoistic, 

W.  W. , .  Subacute  mania,  grandiose,  noisy,  and  obtrusive, 

J.  M.,  .  Calm,  subdued,  demented,     .... 

W.  L.,  .  Wild,  maniacal, incoherent,exiravaga7it  optimism, 

J.  E. ,  .  Subacute  mania,  grandiose  and  egoistic, 

T.  S.,  .  Tremulous  with  excitement,  oiitimistic,  notable  x>aresis, 

R.  C,  .  Calm,  notable  bulbar  pai-alysis,  much  optimism, 

S.  M.,  .  Calm,  dull,  heavy,  demented, 

J.  N.,  .  Heavy  and  demented,  depressed,  much  paresis, 

C.  P.,  .  Dejnessed,  obscure  egoism,  sluggish, 

W.  II.,  .  Mania,  garrulous,  obtrusively  egoistic,  . 

T.  E..,  .  Cheerful,  calm,  slight  dementia,  on  optimism, 

F.  L.,  .  Heavy,  demented,         ..... 


Ace 
Stii 

ustic 
nulus. 
ec. 

Optic 
Stimulus 

Sec. 

16 

•25 

17 

•24 

17 

•24 

IS 

•IS 

IS 

•21 

?, 

18 

•27 

19 

•23 

19 

•24 

20 

•27 

21 

•27 

22 

•23 

24 

•30 

•o.:^ 

.07 

OculO-motor  Symptoms. — The  eye-symptoms  in  general  paralysis 
form  a  highly  characteristic  and  significant  group.     Both  the  extrinsic 


264  GENERAL    PARALYSIS. 

and  intrinsic  muscles  suffer ;  but,  whilst  the  former  present  derange- 
ments in  exceptional  cases  only,  the  lattor  or  intrinsic  muscles  of  the 
eyeball  exhibit  deranged  innervation,  in  some  way  or  other,  in  all 
cases  at  some  stage  of  the  affection. 

The  motor  derangements  of  the  intra-ocular  musculature  are  indi- 
cated by — (a)  size  of  pupils ;  (b)  inequality  ;  (c)  marginal  contour ; 
(d)  mobility;  (e)  reflex  adjustments;  (/)  accommodative  adjustments; 
(g)  accommodative  power.  The  reflex  adjustments  (e),  comprise  the 
pupillary  reactions  to — (1)  cutaneous  or  sympathetic  stimulation;  (2) 
consensual  stimulation;  (3)  direct  light  stimulation.* 

Taking  indiscriminately  a  group  of  general  paralytics  in  various 
stages  of  the  disease,  the  student  may  meet  with  one  or  other  of  the 
following  pupillary  anomalies : — The  pupils  may  be  extremely  small, 
perfectly  fixed  to  light,  so  that  on  exposing  or  shading  the  eye,  no 
movement  can  be  obtained — the  pin-hole  pupil  as  it  has  been  called; 
and  it  is  then  said  to  be  in  a  state  of  spastic  myosis.  Such  a  state 
of  contraction  is  highly  important,  as  being  frequently  present  in 
general  paralysis,  locomotor  ataxy,  and  other  spinal  afi'ections.  The 
pupil  may  be  small  as  the  result  of  paralysis  of  its  dilator  or  circular 
fibres;  this  is  called  paralytic  myosis,  and  may  be  due  to  a  des- 
tructive lesion  in  the  cilio-spinal  regions  of  the  cord ;  in  this  case 
the  pupils  no  longer  dilate  with  atroijine.  It  is  a  rare  affection,  but 
has  been  recorded  by  Baerwinkel  in  sclerosis  of  the  medulla  oblongata.t 
Unilateral  myosis  of  this  description  has  also  been  recorded  by 
Nothnagel  in  disease  of  the  pons.  The  pupils  may  be  unequal  in  size, 
there  may  be  only  the  slightest  degree  of  inequality,  yet  if  associated 
with  other  paretic  symptoms,  or  suspicious  mental  states,  the  ocular 
reflexes  should  be  carefully  examined  ere  the  student  is  pi-epared  to 
discard  such  inequality  as  of  trivial  import.  Care,  of  course,  should 
be  taken  to  exclude  opacities  of  cornea,  capsular  adhesions,  or  retinal 
changes.  The  inequality  may  be  very  extreme  from  paralysis  of  one 
sphincter  iridis. 

One  or  both  pupils  may  be  in  a  state  of  wide  dilatation,  acting 
sluggishly,  or  not  at  all,  to  the  strongest  beam  of  light — a  state  of 
paralytic  mydriasis.      Such  a  condition  may  be  associated   with 

amaurosis. 

Or  the  pupils  may  be  (one  or  both)  ii-regular  in  contour ;  may  be 

*  It  must  be  miderstood  that  the  remarks  in  this  chapter  apply  exclusively  to 
those  persistent  or  gradually  progressive  impairments  of  the  oculo-motor  adjust- 
ments, wholly  irrespective  of  those  variations  in  tlie  size  of  the  pupil  which  may 
occur  from  day  to  day,  and  which  inchule  an  inconstant  factor,  such  as  intra- 
cranial discharges,  &c.,  or  other  source  of  transient  stimulus. 

+  Jour.  Mental  Science,  1878. 


PARALYSES    OF    INTRA-OCULAR    MUSCULATURE.  265 

oval  or  not  quite  circular — the  upper  or  lower  arc  not  conforming  to 
the  circular  outline;  here,  again,  we  must  carefully  exclude  adhesions  and 
effects  of  old  iritis.    At  times  the  irregularity  is  very  marked  and  bizarre. 

Again,  the  reflex  adjustments  may  fail,  and  thus  upon  stimulating 
the  skin  by  the  electric  brush,  or  by  a  pin,  or  by  pinching  the  skin,  we 
do  not  observe  the  usual  dilatation  of  the  pupils  in  one,  or  perhaps  in 
either  case ;  or  upon  alternately  closing  one  or  other  eye,  the  other 
fails  to  exhibit  the  consensual  movements  of  the  normal  state ;  and 
this,  likewise,  may  be  observed  in  one  eye  only  or  in  both.  In  a  state 
of  sjmstic  myosis,  of  course,  both  the  foregoing  reactions  are  abolished. 
"  In  the  healthy  eye  the  consensual  contraction,  according  to  Listing, 
does  not  begin  until  two-fifths  of  a  second  after  the  opening  of  the 
other  eye,  and  lasts  about  one-fifth  of  a  second,  after  which  the  pupil 
again  dilates  slowly,  and  vibrates  for  some  seconds.  The  consensual 
dilatation  he  observed  to  commence  about  half  a  second  after  the 
closing  of  the  other  eye,  and  with  diminishing  rapidity  to  continue  for 
one  or  two  seconds."*  Then  again,  the  sphincter  iridis,  either  when, 
the  pupils  are  equal  or  very  dissimilar  in  size,  may  not  respond  to  the 
stimulus  of  light,  or  may  respond  with  a  sluggishness  evidently  morbid. 
This  condition  of  failure  of  the  light-reflex  without  a  similar  impli- 
cation of  the  accommodative  movements  of  the  iris  is  called  reflex 
iridopleg'ia,  or  the  Argyll-Robei-tson  symptom,  which  is  one  of  great 
significance  in  early  stages  of  tabes  and  general  paralysis.  Yet  again, 
the  sphincter  may  show  no  response  to  light,  nor  to  the  effort  of 
accommodation,  nor  the  movements  of  convergence  and  divergence;  and 
the  resulting  paralysis  we  speak  of  as  an  associative  iridopleg'ia. 

Any  one  of  these  numerous  anomalies  may  present  themselves  in 
the  subjects  of  general  paralysis.  The  contraction  which  occurs  during 
accommodation  for  a  near  object,  and  when  the  eyeballs  are  convergent, 
must  be  regarded  as  of  the  nature  of  an  associated  movement ;  yet  we 
must  not  understand  by  this  that  the  accommodative  movement  is 
involuntary.  "  The  fact  that  this  last  (contraction  during  accommo- 
dation) is  only  an  associated  movement,  does  not  deprive  it  of  its 
voluntary  character,  "t 

The  more  frequent  motor  derangements  met  with  may  thus  be 
summarised  : — 

1.  Spastic  myosis.  5.  Loss  of  sympathetic  reflex. 

2.  Paralytic  mydriasis.  6.  Loss  of  consensual  movements. 

3.  All  degrees  of  irregularity  of  pupil.  7.  Reflex  iridoplegia  (Argyll-Eubertson). 

4.  Irregular    contour    from    partial  S.  Associative  iridoplegia. 

spasm  or  paralysis.  9.   Cycloplegia. 

*  Quoted  by  Bonders,  "Accommodation  and  Refraction  of  the  Eye,"  Stjil.  Soc, 
p.  573.  t  Donders,  loc.  c'U.,  p.  574. 


2GG 


GENFKAL    PARALYSIS. 


As  to  the  relative  frequency  with  which  tliese  derangements  to  the 
iritlo-inuscular  apparatus  occurs,  we  usually  find  as  an  early  sign 
a  slight,  perhaps  scarcely  appreciable,  inequality  of  the  pupils,  the 
sizes  of  M'hich  are  otherwise  not  abnormal,  accompanied  by  a  little 
sluggish  delay  upon  the  part  of  the  larger  in  reacting  to  light,  while 
the  smaller  contracts  and  dilates  briskly.  If  the  light  be  bright 
this  want  of  active  mobility  may  not  be  appreciable,  hence  the 
necessity  of  testing  in  a  subdued  light  as  well  as  by  focal  illumination. 
If  the  patient  be  now  told  to  converge  the  eyeballs,  the  pupils  con- 
tract readily  and  equably,  and  we  regard  the  case  as  one  of  com- 
mencing reflex  iridoplegia.  If  this  be  the  case,  we  shall  now  almost 
certainly  find  associated  with  it,  the  loss  of  the  sympathetic  dilatation 
which  should  occur  on  irritating  the  skin ;  for  this  is,  of  all  other 
iridal  paralyses,  the  earliest  observed.  The  strong  stimulation  of  a 
sensory  nerve  is  well  known  to  inhibit  reflex  actions ;  and  upon  this 
physiological  principle,  Bechterew  would  explain  this  pupillary  dilata- 
tion as,  in  fact,  an  inhibition  of  the  usual  light-reflex ;  it  is  equally 
produced  by  noises  in  the  ear,  or  by  stimulation  of  the  sexual  organs, 
uterine  pain,  kc.  The  constant  association  of  these  two  anomalous 
states  is  readily  explained  by  the  proximity  of  the  sympathetic  tract 
supplying  the  dilator  iridis  to  that  nucleus  of  the  oculo-motor  which 
regulates  the  sphincter  iridis  imder  the  stimulation  of  light. 

The  large  proportion  of  paralytics  who  present  themselves  in  an 
early  stage  will  afibrd  us  these  signs — viz.,  a  moderate-sized  pupil, 
slightly  larger  than  its  fellow,  sluggishly  reacting  to  light,  even  to 
a  bright  beam,  and  absence  of  the  sympathetic  dilatation. 

In  the  more  advanced  stages,  the  larger  puj^il  will  now  be  found 
quite  fixed  to  light  or  may  contract  very  partially ;  and,  if  a  strong 
beam  of  light  be  used  to  illuminate  the  eye,  the  initial  slight  con- 
traction is  followed  by  a  sudden  dilatation  beyond  its  original  limits ; 
remaining  wide  throughout  the  illumination  of  the  retina.  One  eye 
succumbs  to  this  reflex  iridoi")legia  before  the  other ;  but,  we  often 
recognise  a  failing  mobility  in  the  healthier  organ  also,  and  eventually 
both  become  quite  fixed  and  immobile  to  light.  The  small-sized  pupil 
{myosis),  although  usually  noted  at  an  early  stage  of  the  disease,  is  not 
thus  restricted ;  it  may  retain  this  size  throughout  the  disease,  and 
be  a  notable  sign  even  to  the  fatal  termination.  On  the  other  hand, 
mydriasis,  if  not  associated  with  distinct  amaurosis,  is  a  feature  of 
the  later  stage  of  general  paralysis.  The  student  would  do  well,  when 
examining  the  eye  of  a  presumed  case  of  general  jiaralysis,  not  only 
to  measure  with  the  pupilometer  but  also  to  compare  the  dimensions 
with  the  healthy  eyes  of  those  standing  by,  under  the  same  intensity  of 
light.      As  the    small    pupil   in  the    early   days   of  general  paralysis 


PUPILLARY    ANOMALIES. 


267 


becomes  gradually  larger  with  advancing  reflex  iridoplegia,  it  afTords  us 
evidence  of  a  deeper  implication  of  the  nuclei  in  one  half  of  the  pons, 
as  loell  as  of  the  cerebral  hemisplcere  of  the  same  side  ;  for  it  has  con- 
stantly occurred  to  the  writer  to  observe  that  when  unilateral  convul- 
sions or  paralysis  occur  in  the  early  stages  of  general  paralysis,  the 
dilated  pupil  is  07i  the  side  of  the  discharging/  or  2y<^i'(d!/sing  lesion* 
It  appears  to  us  unquestionable  that  the  oculo-motor  disturbances, 
Avliich  we  have  above  alluded  to,  are  greater  on  the  side  of  the  more 
deeply-implicated  hemisphere. 

The  pi7ihead  jmjjil  may  2:)ersist  to  the  end,  and  yet  present  no  impair- 
ment of  the  associated  movements  on  accommodation,  as  in  the 
followinc:  cases  : — 


Size  of  Pui'Ils. 

Reaction  to  Stmpathetic 
Light.            Beflf.x. 

consf.kscal 
Bf.flkx. 

Accommodation. 

D.  K. 

S.  A.  L. 

1 .,.- millimetres. 
1  o 

1-5 

1-7^  millimetres. 

Immobile. 
Immobile. 

Immobile. 
Immobile. 

Immobile. 

Slight    in 
left  only. 

Normal  and  ac- 
tive. 

Brisk. 

In  estimating  the  significance  of  these  ocnlo-motor  anomalies,  the  student  must 
bear  in  mind  the  teaching  of  experimental  physiology  upon  the  subject,  which 
demonstrates 

(1)  That  centripetal  retinal  excitations  travel  by  way  of  the  optic  nerve  and 
tracts  to  tlie  upper  quadrigeminal  arc,  i.e.,  by  the  nates,  its  hrachki,  the  external 
geniadate,  and  the  pjtlvinar  of  the  optic  thalamus,  which  constitute  a  first  stage  or 
level,  and  from  which  such  excitations  pass  by  the  optic  radiations  to  the  occipito- 
angular  region,  or  visual  centre  of  Ferrier. 

(2)  That  section  of  one  optic  nerve  causes  monocular  blindness,  together  with 
loss  of  the  light-reflex  {reflex  iridoplegia)  of  the  same  eye,  still  with  persistent 
contraction  of  both  eyes  on  stimulation  of  the  second  eye — a  phenomenon  explained 
by  the  coupling  of  the  oculo-motor  nuclei. 

(3)  That  section  of  one  optic  tract  issues  in  homonymous  hemiopia,  from  paraly- 
sis of  the  corresponding  retinal  halves  of  both  eyes.  Whilst  Bechterew  shows 
that,  in  the  dog,  division  of  one  tract  is  unaltered  by  reflex  contraction  of  the 
constrictor  iridis.  Knoll  indicates  that  in  the  rabbit  (with  its  complete  decussation 
at  the  chiasma)  division  of  one  tract  abolishes  the  light-reflex  in  the  opposite  eye. 

(4)  That  enucleation  of  one  eyeball  in  animals  with  fairly  complete  decussation 
at  chiasma  (rabbit)  issues  in  atrophy  of  the  nates,  its  brachia,  and  external  genicu- 
late, with  the  pidvinar,  all  of  the  opposite  side ;  that  in  animals  with  very  incom- 
plete decussation,  i.e.,  where  the  direct  fibres  preponderate  (Erh  and  Day),  such 
atrophy  pertains  more  equally  to  these  parts  on  both  sides.  The  representation  of 
the  retinal  fields  in  these  ganglionic  centra  Ijehind  the  optic  commissure  will  vary 
with  the  animal ;  and  so  lesions  of  the  tract  or  of  the  quadrigeminal  body  of  one 


See  Article  by  Author  in  West  Biding  Asylum  Reports,  vol.  vi. 


26S  GENERAL    PARALYSIS. 

side  will  issue  in  varj-ing  results.  Thus  Baunii,'arten  *  records  secondary  degener- 
ation of  both  optic  tracts  in  man  after  destruction  of  one  eye. 

In  this  lower  arc,  therefore,  connecting  the  retina  with  the  mesencephalic 
centres,  we  find  that  section  and  destructive  lesions  on  tlie  peripheral  side  of  the 
ganglia  issue  in — 

Partial  or  complete  amaurosis,  with  partial  loss  of  the  consensual  reflex  and 

reflex -iridoplegia. 
Homonymous  hemiopia,  with,  or  without,  impairment  of  light-reflex ;  certain 

secondary  degenerative  changes  affecting  the  tracts  and  the  (juadrigeminal 

structures  with  the  pulvinar  alluded  to  above. 

In  like  manner,  destruction  of  these  ganglia  also  issue  in  degenerative  changes 
in  both  optic  nerves,  especially  that  opposite  the  lesion.  Such  degenerations  are 
limited  to  this  arc,  and  do  not  travel  centralbj  beyond  the  quadrigeminal  centres  to 
the  cerebral  cortex. 

On  the  other  hand,  the  upper  arc  of  optic  radiations  is  connected  with  the 
visual  perceptive  centres  of  the  cortex.  Its  division  is  followed  by  atrophy  of  the 
cortex  and  of  the  quadrigeminal  arc,  as  well  as  of  the  lower  arc  connected  with 
the  retina ;  but  it  must  be  remembered  that  the  retinal  reflexes  are  not  abolished 
by  lesion  above  the  mesencephalon. 

Size  of  Pupils. — The  pupillary  aperture  is  more  frequently  found 
dilated  than  unduly  small  and  constricted,  and  a  moderate-sized  pupil 
is  less  frequent  than  one  distinctly  larger  than  usual.  In  fact,  if  "we 
take  note  of  all  cases  of  unilateral  mydriasis,  as  well  as  of  those 
wherein  both  are  dilated,  we  shall  find  that  it  is  met  with  in  one- 
half  of  our  cases.  If  we  arbitrarily  assume  any  size  up  to  2  milli- 
metres diameter  to  include  the  small  or  contracted  2)^2^11,  from  above 
2  millimetres  to  3  millimetres  for  the  moderate-sized  2iU2^il,  and  all 
above  3  millimetres  as  large  dilated  pupils,  we  get  the  following 
propox'tions : — 

Small  contracted  pupil,         ....       4  cases. 

Moderate-sized,     .         .         .         .         .         .     13      ,, 

Dilated, ^7      „ 

In  about  half  the  cases,  i.e.,  in  twenty-one,  one  or  both  pupils  measured 
-i  millimetres  or  upwards,  and  in  six  of  these  cases  both  pupils  were 
equal  in  size.  Very  large  pupils — 6  to  7  millimetres — prevailed  in 
three  cases  (see  Summary,  pp.  269-273).  In  the  Summary,  the  upper 
figure  of  the  fraction  in  col.  2,  and  corresponding  line  in  col.  3,  indi- 
cate in  each  case  the  size  of  pupillary  aperture  and  iridal  reactions 
of  the  right  eye  ;  the  lower  figure  and  line  refer  to  the  same  features 
in  the  left  eye.    In  all  other  cases  the  i-eactions  are  alike  for  both  eyes. 

*  Central-hlatt.  f.  d.  Med.  Wisaenschajt,  1SS3.     (Quoted  by /erncr.) 


ANALYSIS  OF  OCULAR  DERANGEMENTS. 


269 


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270 


OCULO-MOTOn    ANOMALIES. 

Summary  of  Oculo-Motou  and  Associated  Anomalies  in 


Size 

iu 
mm. 

Light-Uenes. 

Focal  Illuminatioa 

ConsensuaL 

Ilenex 
Dilatation. 

Associated 
Movement 

J.W.  M., 

45- 
3 

Almost  fixed. 
Slight  contii. 

Slight  contn. 

Normal. 

Fixed. 

Normal. 

J.  0.  0., 

3 
4 

Slight. 
Normal. 

Slight. 
Normal. 

>> 

>> 

>> 

M.  P.,     . 

2^ 
4 

Normal. 

Normal. 

>, 

>> 

>> 

A.  S.,      . 

34 

44 

)> 

,, 

Sluggish. 

)> 

Sluggish. 

J.  D.,      . 

4 

H 

Sluggish. 

Slight,  then  oscillates. 
2dy  dilatation. 

Normal. 

Normal. 

Normal. 

M.  B.,     . 

3 
3 

Normal. 

Normal. 

>j 

Fixed. 

>» 

L.  B.,      . 

24 

" 

Normal  for  both. 
2dy  dilatation. 

>. 

Normal. 

»> 

F.  S.,      . 

4 
4 

)) 

Normal. 

>  > 

Normal. 

Sluggish. 

>> 

K.  T.,     . 

3 

>y 

" 

Normal. 
Dilates. 

Sluggish. 

>> 

S.  S.,      . 

2 
2 

" 

>  J 

Normal. 

Normal. 

>> 

J.  P.,      . 

3i 

- 

jj 

" 

Fixed. 

>> 

J.  w.,    . 

3 
3 

Sluggish. 

Normal,  then  oscillates. 
2('y  dilatation. 

>) 

Normal. 

Normal. 

Sluggish. 

J.  L.,      . 

9L 

3 

Sluggish  and  of 
limited  range. 

Normal  but  of 
limited  range. 

,, 

Slight. 

NormaL 

R.  S.,      . 

91 

24 

Fixed. 
Slight. 

Slight. 
Normal. 

)> 

Normal. 

)> 

A.  H.,     . 

S.  A.  L., 

2 

3 

1-5 
1-5 

Fixed. 

Fixed. 

Sluggish. 

Fixed. 

Fixed. 

Slight. 
Fixed. 
Slight. 

Fixed. 
Slight. 

Fixed. 

Fixed. 
Slight. 

NormaL 

D.  R.,     . 

1? 
14 

>> 

>) 

Fixed. 

>i 

>i 

J.  W.,     . 

If 

>) 

Fixed  or  of  extremely 
limited  range. 

" 

" 

Extremely 
sluggish 

and 
limited. 

G.  B.,     . 
T.  W.  H., 

2 

ol 

-4 

3 

" 

Fixed. 

19 

>» 
>» 

>> 
»> 

NormaL 

J.  C,      . 

24 

" 

»» 

1 
i 

)> 

>i 

oculo-motoii  anomalies. 
Forty-Four  Cases  of  General  Paralysis. 


271 


Accom- 
modation. 


Visual  Acuity. 


Colour 
fcjense. 


Patella- 
Kellcx. 


Plantar 
llelle.x. 


Gait,  &c. 


J.  22  S"-  24 
J-  22  ^"-  '22 

J.  No.  4 
J.  No.  4 


Sn. 
Sn. 


Normal. 


Sn.  ? 


Sn.   -  Sn. 

Sn.  ^    Sn. 
b 


No.  2 


s».- 


?  dil. 

6 


J. 


16 


J    ^ 


28 


J.No.3Sn.„" 
2o 


Sn. 


34 


J.  1  Sn. 


25 


Sn. 


30 


J.No.lSu, 


20 


J. 

1 
20 

Sn 

2i 
20 

Sn. 


Sn. 


10 
6^ 
12 


Q       6 


Sn. 


Sn. 


Sn. 


30 


10 


10 

Sn.  - 


Sn. 


Sn.| 


Sn. 


Sn 


Sn. 


Sn. 


Normal 

but  green 

=  blue. 

Normal. 


Normal 

but  b.  = 

puce,  y.  " 

pink. 

Normal 

but  b.  = 

green. 

y.  =  orange 

g.  =  puce. 


Normal. 


Normal 
but  green, 
more  like 
blue  than 

yellow. 

r.  =  pink, 

y.  =  purple, 

b.  &  green 

=  Normal. 

Normal. 


Normal 
but  green 
=  yellow. 


Normal. 
Exag. 

Slightly 
exag. 

Sluggish. 
Normal. 


Sluggish. 

Almost 
absent. 

Exag. 


Normal. 
Absent. 


Sluggish. 
Normal. 


Exag. 
Normal. 

SI.  exag. 

Slight. 
Absent. 

Absent. 


Normal. 


Sluggish. 

Normal. 

Absent. 
Exag. 

Normal. 


Exac. 


Absent. 


Exag. 
Normal. 

Normal. 

Sluggish. 

Normal. 


Brisk. 

Brisk. 

Brisk. 

Brisk,  trunk  stiff. 

Brisk. 

Brisk. 

Brisk. 

Brisk,  and  runs. 

Sways,  staggers,  and  leans  to  right. 
Stiff,  tottering,  feeble. 

Brisk,  but  stiff,  a  little  tottering. 

Stooping,  staggering,  and  falls  if  eyes 
be  closed. 

Brisk. 

Right  leg  stiff — not  dragged  ~  right 
hemiplegia  c.  aphasia,  horizontal 
nystagmus. 

Stiff,  slow,  sways. 
Brisk,  elastic. 

Brisk  and  springy. 

Slow,  laboured,  leans  to  left  side. 

Brisk. 

Stiff. 

Stiff. 


OCULO-MOTOU   ANOMALIES. 


Size 

In 

mm. 

Light-Reflex. 

Focal  Illumination. 

Consensual. 

Ri-flet 
Dilatation. 

A880ciat«d 
Movement. 

J.  H.  W., 

2? 

Fixed. 

Fixed. 

Sli-ht. 
Fixed. 

Fixed. 

Normal. 

B.K.,     . 

34 

>) 

II 

Fixed. 

)» 

Fixed. 

W.  M.,  . 

3 

3 

»» 

>i 

)i 

>i 

II 

C.  J.  C, . 

>> 

II 

M 

>) 

Fixed. 
Normal. 

J.  J.,      . 

4 

j> 

II 

)l 

>> 

Sluggish. 

J.  H.,      . 

4 
3 

» 

11 

11 

)) 

Fixed, 
Normal. 

J.  L.,      . 

4^ 
44 

,, 

>» 

,, 

,, 

Fixed. 

J.  C.  C, 

64 
6 

»> 

II 

1) 

u 

II 

J.  M.,     . 

7 
5 

)j 

II 

.' 

M 

II 

J.  A.,      . 

34 
4| 

Slight,  2'ly  dilatation. 
Fixed. 

II 

,, 

)  I 

?dil. 

E.  B.,     . 

2i 
1^ 

Fixed. 
Slight,  2Jy  dilatation. 

Fixed. 
Slight,  2iy  dilatation. 

5) 

,, 

Normal. 

J.  H.,      . 

34 

Sluggish. 

Sluggish. 
2'ly  dilatation. 

Slight. 

Normal. 
Slight. 

.. 

A.  S.,      . 

4 
4 

Normal. 
Sluggish. 

Normal. 
Sluggish,  2'ly  dilatation. 

Fixed. 

Fixed. 

1) 

J.  T.,      . 
T.  T.,      . 

4 

M 
4 

4 

Sluggish  and  of 
limited  range. 

Sluggish  and  of 
limited  range. 

Sluggish. 
Sluggish. 
Normal. 
Sluggish. 

Sluggish. 

Fixed. 

Sluggish. 

Slight. 

>> 

C.  G.,     . 

6 
6 

Sluggish. 

Normal  with 
2''y  dilatation. 

>i 

Sluggish, 
Fixed. 

Sluggish. 

J.  M.,     . 

2i 
0 

Slight  with 
2'ly  dilatation. 

Slight  with 
2<ly  dilatation. 

Fixed. 

Fixed. 

Normal, 

J.  B.,      . 

3^^ 
3i 

)> 

Normal  witli 
2'ly  dilatation. 

,, 

)) 

i> 

W.  T.  S., 

W.  S.,    . 

■1 

44 
4.^ 
4i 
3? 

Slug-ish. 
Sluggish. 

Sluggish. 

Normal. 

Sluggish,  2'ly  dilatation. 

Normal,  then  oscillates 

with  2'ly  dilatation. 

Normal. 
Sluggish. 

Sluggish. 

Sluggish, 

Sluggish. 
Fixed, 

Normal, 
Sluggish. 

Normal. 

H.  M.,    . 

3 

2? 

SlUfT-ish. 

Fixed. 

Normal. 
Fixed, 

Normal. 
Fixed. 

Fixed. 

Slight. 
Fixed, 

B.  H.,     . 

4 
3 

Slight. 

Slight. 

Slight. 

>> 

Normal, 

'J.  B.,      . 

44 

44 

Slight  with 
2'ly  dilatation. 

Slight,  2'ly  dilatation. 
Normal,  2'ly  dilatation. 

)> 

9 

»} 

Note.  —The  upper  figure  of  the  fraction  in  col.  2  and  corresjionding  line  indicate  in  each  case  the  size 

same  features  in  the  left  eye.     In  all  other 


OCULO-MOTOR    ANOMALIES. 


273 


Accom- 
modation. 


^■i 


S°-20^"-  20 


J.  No.  1  Sn.  "o 
J-  25  ^''-  2f, 


J.  No.  2 


J- 2^4 
?  dilatn. 

^^•27 
?  dilatn. 

Sn.  ;4 

1/ 


S"-fs 


Visual  Acuily. 


Colour 
Sense. 


Sn. 


Sn.  50  only 
Sn.^Sn.-*^ 


Sn. 
Sn. 


s°-  ro  ^"-  (5 


Sn. 


Normal. 


2 

19 
5 
21 


J. 

J. 

J.  No.  1 
J.  No.  4 


J. 


42 


Su. 

Su. 

Sn. 
Sn. 
Sn. 


10 


18 


_6 
24 
6^ 
40 

10 

^"•10 
Sn.5 


Sn. 


30 


Sn.  ,;   Sn.  - 
b  o 


Normal 
but  gv.  =': 

Normal. 

Normal 

but  y.  =? 

Normal. 

Normal 

but  gr. 

=  yellow. 


Normal. 


Normal 

but  gr. 

=  crimson, 


Normal. 

Normal 
but  gr. 
=  puce. 

Normal. 


r.itella- 
Itellex. 


Normal. 


Normal. 


Exag. 


Normal. 
Exacc. 


Absent. 

Exag. 
clonos. 

Almost  nil, 


Exag. 

Absent. 

Exag. 

Normal. 

Sluggish. 
Normal. 

Exag. 

Absent. 

Normal. 

Exag. 

Exag. 
Absent. 

Absent. 
Sluggish. 

Exag. 


Plantar 
Keflex. 


Sluggish. 

Nonnal. 
Absent. 
Normal. 

Exag. 
Sluggish. 
Normal. 

Sluggish. 

Normal. 

Slight. 

Sluggish. 

Exag. 

Sluggish. 
Normal. 


Sluggish. 
Normal. 

Exag. 
Normal. 


Normal. 
Sluggish. 


Stiff,  broad  basis,  heels  down  first. 

Legs  drop,  left  hemiplegia  =  contrac- 
ture of  left  arm,  cannot  stand  un- 
supported. 

Brisk. 

Leans  to  left  side. 
Stiff. 

Brisk. 

Quick,  elastic.  Both  lenses  opales- 
cent. 

Brisk. 

Flexion  and  rigidity  of  both  legs  and 
right  elbow;  cannot  stand.  Adhe- 
sions in  both,  pigmentary  deposit 
on  front  of  lens. 

Stiff,  waddling,  but  stands  unsup- 
ported. 

Stiff. 


Heavy,  tottering. 

Stooping,  bent,  unsteady,  insecure. 

Left  eye  strongly  convergent  when 
eyes  are  directed  to  right. 

Brisk. 


Brisk. 

Brisk. 

Right  leg  dragged  ;    right  arm  con- 
tracted ;  feeble  gi-asp. 

Brisk. 

Brisk,  spring}'. 

Stooping,  shuffling,  most  hisecure. 

Stiff. 

Cannot  walk  or  stand. 


of  pupillary  aperture,  and  iridal  reactions  of  the  right  eye  :  the  lower  figure  and  line  refer  to  the 
cases  the  reactions  are  alike  for  both  eyes. 

18 


274  GENERAL    PARALYSIS. 

Unilateral  deviations  were  noted  in  twenty-seven  cases,  the  remain- 
ing seventeen  having  pupils  of  equal  dimensions.  In  sixteen  cases  the 
right,  and  in  eleven  cases  the  left,  was  the  larger  pupil  of  the  two. 

Lig'ht-Peflex. — Referring  to  our  table  of  actual  figures,  it  is  found 
that  over  3G  per  cent,  have  hoth  pupils  'perjtclhj  immobile  and  fixed 
to  the  stimulus  of  light,  and  that  half  as  many  again,  i.e.,  18  per 
cent.,  show  fixity  or  sluggish  reaction  in  one  or  other  eye.  Further, 
in  11  per  cent,  both  pupils  were  noted  as  excessively  sluggish  in 
reaction  and  limited  in  their  range,  and  in  18  per  cent,  only 
could  it  be  stated  that  the  pupils  reacted  normally  under  the  stimulus 
of  light.  The  immobility  of  the  pupils  is  rigid  even  to  focal  illumina- 
tion of  the  eye  by  a  convex  lens,  and  with  a  strong  light — as  many  as 
24  per  cent,  still  exhibiting  both  pupils  immobile. 

An  early  indication  of  commencing  iridoplegia  is  given  by  focal 
illumination,  for,  as  shown  by  the  table,  13-6  per  cent.,  although  active 
to  light,  show  (for  a  concentrated  beam  of  light)  a  most  limited  range 
of  movement,  together  with  an  oscillation  which  then  tends  to  wide 
dilatation  even  under  this  bright  illumination  of  the  retina.  This  ten- 
dency to  dilate  during  stimulation  by  light  appears  to  me  to  be  the 
earliest  augury  of  coming  pai'alysis. 

Consensual  Movements. —  These  reactions  were  abolished  in 
43  per  cent,  of  the  total  cases,  and  were  almost  invariably  absent 
where  the  light-reflex  was  absent  in  both  pujnls.  A  considerable 
number,  however,  of  cases  of  incomplete  or  commencing  paralysis  to 
light  showed  perfectly  normal  consensual  movements  (25  per  cent.), 
or  but  slight  impairment,  amounting  to  sluggish  response  or  unequal 
response,  on  both  sides. 

The  failure  of  the  consensual  movements  apparently  never  occurs 
apart  from  impairment  of  the  direct  or  light-reflex  (the  only  excep- 
tion, if  it  is  one  at  all,  is  that  of  K.  T.,  where  very  sluggish  dilatation 
is  noted  with  normal  light-reflex):  It  appears  invariably  to  follow 
upon  the  latter  impairment,  and  thus  we  find  in  a  few  cases  [R.  S., 
e.g.),  that  the  light-reflex  is  impaired,  whilst  the  consensual  activity  is 
normal  in  both  eyes. 

Reflex  Dilatation  {Erb). — This  movement,  which,  as  before  stated, 
Bechterew  regards  in  the  light  of  an  inhibitory  action,  fails  at  an  early 
date.  It  was  completely  abolished  in  63 "6  per  cent.,  and  normal 
response  was  obtained  only  in  11-3  per  cent.  Excitation  of  any  avail- 
able sensory  surface  alike  fails  to  produce  response  in  such  cases ;  and, 
it  is  of  interest  to  note,  that  unilateral  failure  of  this  reflex  dilatation 
also  occurs  (being  present  in  13*6  per  cent.)  In  several  of  the  cases 
tabulated,  it  will  be  noted  that  this  reflex  dilatation  failed  where  the 
pupils  showed  healthy  and  active  response  to  the  stimulus  of  light, 


REFLEX    IRIDOPLEGIA.  275 

both  directly  and  consensually  (see  U.  P.  ;  A.  S.  ;  M.  B. ;  K.  T.  ;  and 
J.  P.)  This  anomalous  condition  we  believe  to  be  the  earliest  sign  of 
approaching  irido-raotor  implication  ;  following  in  its  wake  comes  the 
sluggish  reaction  of  one  pupil  to  light  with  a  tendency  to  dilate  on 
sustained  illumination  ;  then  a  gradually  extending  paralytic  mydriasis, 
with  which  becomes  associated  the  impairment  of  consensual  activity. 

Associated  Irido-MotOP  States. — The  associated  movements  of 
contraction  and  dilatation  of  the  pupil  during  the  act  of  accommodation 
and  eflbrts  of  convergence  are  affected  only  in  the  later  stages  of  the 
disease;  and  in  five  cases  only  (or  11-3  per  cent.)  was  it  absolutely 
lost  in  both  eyes ;  whilst,  as  many  as  twenty-eight  (or  63-6  per  cent.) 
showed  perfectly-normal  response.  It  may  likewise  show  unilateral 
impairment  or  abolition ;  and  in  several  cases  i^F.  B. ;  C.  J.  C; 
A.  H. ;  and  J.  W.)  with  complete  abolition  of  the  light-reflex  in  both 
eyes,  the  associated  iridoplegia  appeared  but  on  one  side,  the  other 
pupil  acting  vigorously  to  convergent  efforts.* 

From  the  study  of  a  large  number  of  cases  of  paralytics  showing 
these  oculo-motor  troubles,  it  appears  to  us  that — 

Firstly,  the  smaller  pupil  is  upon  the  side  of  lesion  of  the  oculo- 
motor nucleus,  or  the  larger  pupil  is  opposite  to  the  nucleus  involved. 

Secondly,  that  the  smaller  pupil  is  the  one  which  fails  to  act  con- 
sensually, if  one  only  shows  a  faikire  in  this  respect. 

Thirdly,  that  the  smaller  pupil  is  the  one  in  which  light-reflex 
is  most  impaii'ed  or  is  abolished,  if  both  are  not  equally  implicated  in 
this  respect. 

If  it  be  accepted  that  the  path  of  the  light-reflex  is  through  the 
central  decussating  fibres  of  the  chiasma  to  the  opposite  oculo-motor 
nucleus  (the  decussating  opto-geniculate  tracts),  as  well  as  to  the 
constrictor  centre  of  the  same  side  by  means  of  the  intercentral  link, 
then  a  lesion  of  one  centre,  say  the  right  motor-oculi,  will  intercept 
the  path  of  stimuli  between,  the  left  retinal  field  and  both  irides.  But 
although  the  left  eye  can  pass  no  stimuli  to  either  constrictor  jmpillce,. 
its  iris  can  still  be  affected  by  stimulation  of  the  opposite  eye,  through 
the  crossed  opto-geniculate  tract,  or  even  through  the  inter-retinal 
commissure.  The  left  pupil,  therefore,  as  well  as  the  right,  would  be 
paralysed  or  fixed  to  direct  light  stimulation  ;  but  whilst  the  left  would 
still  be  consensually  afiected,  the  right  would  be  fixed  to  both  in- 
fluences. The  six  cases  afforded  by  our  series  confirm  these  A'iews  in 
every  respect. 

*  It  has  been  conclusively  shown  by  Donders,  as  well  as  by  De  Ruiter  and 
Cramer,  that  the  associated  contraction  of  the  pupil  occurs  with  the  act  of  accom- 
modation, when  there  is  no  increased  convergence  of  the  visual  Hnc,  and  also  with 
the  latter  when  there  is  no  change  in  acconunodation,     Loc.  cit.,  p.  574. 


27G  GENERAL    PARALYSIS. 

It  thus  appears  tliat  tliore  are  two  links  betwixt  the  quadri- 
geminal  centres  and  tlie  coi'tex.  on  tlie  one  hand,  and  tlie  jieriphery 
on  the  other.  An  upper  cortical  und  a  lower  or  retinal — consisting 
respectively  of  the  optic  radiations  from  the  thalamus  and  mesen- 
cephalon, extending  to  the  occipito-angular  region ;  and  a  lower  link 
from  the  retina  to  the  mesencephalon ;  the  upper  being  essential  for 
visual  perceptions — the  lower  being  also  the  centripetal  paths  for  the 
irido-motor  reflexes.  Lesions  of  the  lower  retinal  link  are  productive 
of  secondary  changes  backwards  to  the  quadrigeminal  regions  (Obs,  4, 
p.  267),  but  not  beyond  this  limit ;  lesions  of  the  upi)er  or  cortical 
link  cause  degenerations,  which  spread  both  centrally  and  peripheri- 
cally,  involving  both  cortex,  optic  tracts,  and  the  intervening  ganglionic 
centre.  The  immediate  result  of  a  lesion  of  one  of  the  lower  links  is 
impairment  of  vision — either  complete  amaurosis  or  paralysis  of  the 
associated  retinal  tields  [equatorial  or  liomonymous  hemlojna),  the  irido- 
motor  reflexes  being  involved  only  when  the  lesion  is  on  the  peripheral 
side  of  the  chiasma.  Since,  howevei",  the  escape  of  the  irido-motor 
reflexes  depends  (in  this  case,  when  the  nuclei  in  the  medulla  are 
intact)  upon  the  commissural  connections,  incomplete  implication  of 
both  tracts  must  necessarily  result  not  only  in  visual,  but  also  in  reflex- 
iridal,  disturbances.  On  the  other  hand,  the  cortical,  or  upper  link, 
when  first  implicated,  has  visual  disturbances  only  for  its  symptoms, 
for  the  ii'idal  reflexes  are  not  involved ;  and  thus  complete  blindness 
with  still  active  pupils  indicates  a  blindness  due  to  cortical  lesion  or  one 
beyond  the  quadrigeminal  bodies  (this  condition  as  a  functional  dis- 
turbance occurs,  e.g.,  in  urcemic  poisoning).  Eventually,  however,  the 
consecutive  degeneration  passing  to  the  upper  quadrigeminal  and 
external  geniculate  bodies,  etc.,  leads  also  to  disturbances  of  irido-motor 
reaction.  The  individual  nuclei,  defined  by  Henson  and  Yoelcker  as 
extending  in  front  of  the  aqueduct,  may,  however,  be  picked  out  by 
morbid  processes;  and,  in  this  case,  the  iridal  reactions  sufier  without 
any  necessary  implication  of  vision,  a  condition  frequently  seen  in  the 
early  stages  of  general  paralysis. 

Spinal  Symptoms. — In  a  large  projiortion  of  subjects  of  general 
paralysis  the  failure  in  the  vigour  and  co-ordination  of  the  greater 
raxxsculatures  comes  on  veiy  gradually  and  insidiously ;  the  lower 
extremities  remain  unart"ected  to  any  appreciable  extent  for  even  two 
or  three  yeai-s  after  the  onset  of  the  attack.  Locomotion  is  unre- 
stricted, equilibration  is  good,  the  gait  steady,  firm,  and  no  swaying 
is  induced  on  closing  the  eyes.  In  fact,  in  50  per  cent,  of  the  cases 
examined  the  walk  was  brisk  and  not  devoid  of  spring,  and  no 
muscular  enfeeblement  was  apparent.  Yet  although  the  rule  is  that  a 
gradually  progressive  paresis  occurs,  in  a  considerable  number  of  cases 


SPINAL    SYMPTOMS    IN    GENERAL    PARALYSIS.  277 

ft  sudden  paralytic  seizure  may  occur,  rendering  the  patient  temporarily 
luilpless  in  his  limbs,  or  permanently  paralysed  with  exalted  reflexes  and. 
contractions  established  by  consecutive  spinal  degenerative  changes.  In 
other  cases,  again,  we  find  the  deep  reflexes  abolished,  and  true  tabetic 
symptoms  obtrude  themselves,  of  transient  duration  only ;  on  their 
disappearance,  hemiplegia  or  convulsive  seizures  may  occur,  and  symp- 
toms of  a  descending  lateral  sclerosis  come  to  the  fore.  The  fre- 
quency with  which  we  meet  with  spinal  symptoms,  and  the  general 
nature  of  these  moi'bid  signs,  may  be  gleaned  from  an  analysis  of  the 
forty-four  cases  before  referred  to.  In  six  cases  only  (or  13-G  per 
cent.)  were  the  deep  reflexes  ascertained  to  be  perfectly  normal ;  in 
sixteen  cases  (or  36  per  cent.)  they  were  decidedly  exaggerated ; 
whilst  in  some  eleven  cases  (or  25  per  cent.)  the  patellar  reflexes 
were  both  abolished,  or  both  very  sluggish ;  in  three  more  cases  the 
knee-jerk  was  abolished  on  one  side,  and  in  a  fourth  very  nearly 
absent.  Thus  we  see  a  very  notable  degree  of  impairment  of  the 
deep  reflexes  characterises  the  afi'ection,  and  the  general  results  may 
be  thus  tabulated  : — 


Deep  R 

EFLEXES. 

s^nee-jerk 

normal  on  both  sides 

in 

6 

cases 

(13-6 

per  cent. ) 

exaggerated 

absent 

very  sluggish 

absent  on  one  side 

nearly  absent 

either  exaggerated 

doubtful 

or 

sluggish 

16 

7 
4 
3 
1 
4 
3 

(36-3 
(15-9 
(  9 
(  6-8 
(  2-2 
(  9 
(  6-8 

r,  ) 

) 

] 

j34 

15  or 

per  cent 

Increased  Knee-jerk. — The  exaggerated  knee-jerk,  it  will  be 
observed,  is  tlie  more  frequent  phenomenon ;  it  may  be  a  purely 
functional  disturbance,  ti'ansient  in  dui^ation,  induced  by  nervous 
discharge  from  the  cerebral  cortex,  and  hence  by  removal  of  its 
inhibitory  control.  In  this  connection  it  is  often  found  as  the  im- 
mediate result  of  a  general  convulsive  seizure,  or  as  actually  accom- 
panying the  convulsive  twitching  of  general  jmralysis ;  on  the  other 
hand,  it  may  be  a  sign  of  organic  disease  of  the  spinal  coxxl,  and  have 
as  its  accompaniments  the  usual  motor  enfeeblement  and  muscular 
contractions  of  descending  sclei'osis.  The  former  association  is  illus- 
trated by  the  table,  which  shows  that  out  of  twenty-two  cases  where 
the  gait  was  elastic  and  brisk,  seven  present  very  notable  increase 
of  knee-jerk.  It  is  important,  therefore,  to  note  that  we  have  as 
associated  phenomena  in  many  cases  of  general  paralysis,  a  firm  elastic 
walk,  loith  full  muscidar  vigour  of  limbs,  exaggerated  deep .  reflexes,  and 
pronounced  irido-motor  j'ici.ralysis. 


278  GENERAL    PARALYSIS. 

The  latter  association — i.e.,  of  increased  knee-jerk  with  structural 
disease  of  cord,  is  exemplified  in  cases  /.  M.,  J..B.,  Ji.  S.,  B.  K.,  and 
may  be  instructively  associated  with  the  ocular  troubles  as  follows  : — 

Case — J.  ISI. — Riglit  aiiii  and  Ijotli  legs  paralysed  and  contracted ;  knee-jerk  notably 

exaggerated  in  both  ;  marked  ocular  paralysis. 
„      J.  B. — Right  aim  ])aralysed  and  rigid  ;  right  leg  drags  ;  knee-jerk  notably 

exaggerated  in  right ;  marked  ocular  paralysis. 
,,      R.  S. — Right  henuplegia  with  aphasia;  right  leg  stiff;  knee-jerk  notably 

exaggerated  in  right ;  marked  ocular  paralysis. 
,,      B.  K. — Left  hemiplegia  with  contractures;  knee-jerk  notably  exaggerated  in 

right ;  horizontal  nystagmus  ;  ocular  troubles. 

Besides  the  above,  sevei-al  (three)  of  the  cases  of  hemiplegia,  with  early 
commencing  changes  in  the  cord,  were  found  associated  with  disturbed 
reflexes  and  marked  intra-ocular  pai-alysis. 

M.  J.  R.,  aged  thirty-six,  a  gardener's  wife,  with  a  family  of  three  children, 
was  admitted  May  24,  1882.  It  was  stated  that  for  the  past  ten  months  she  had 
suffered  from  "fits," 'the  last  seizure  a  month  since,  leaving  her  in  her  present 
demented  state.  No  hereditary  predisposition  could  be  ascertained,  no  history  of 
drink,  or  syphilis.  She  understood  all  that  was  said  to  her,  but  was  incorrect  in 
all  her  replies  involving  time,  dates,  and  locality  ;  she  did  not  recognise  the  nature 
of  her  surroundings,  and  memory  was  faulty  regardmg  recent  and  remote  events. 
Was  very  emotional,  wept  constantly,  and  wished  to  go  home.  She  betrayed  much 
self-satisfaction,  was  inclined  to  joke  and  laugh  at  her  own  statements,  adding — 
"Not  such  a  bad  wife  after  all,  am  I?"  The  right  pupil  was  the  larger  of  the 
two,  but  both  were  regular  in  contour  and  active  in  their  reactions ;  the  tongue 
and  lips  were  tremulous  and  speech  somewhat  impaired.  The  grasp  of  tlie  right 
hand  was  much  weakened ;  she  was  in  good  bodily  condition.  She  continued 
thus  at  times  depressed,  at  times  irritable  and  interfering,  fretful  and  discontented 
until  August  9,  when  several  seizui-es  were  noted  affecting  left  side  of  face  and 
arm,  but  continuing  only  a  few  moments ;  the  arm  was  left  powerless,  and  remained 
so  for  twelve  hours. 

About  nine  months  after  admission  it  is  noted  : — Patient  can  stand  with  eyes 
closed,  but  staggers  much  on  endeavouring  to  walk  along  a  straight  line ;  she 
is  more  feeble.  Knee-jerk  exaggerated  on  right  and  normal  on  left  side  ;  ankle- 
clonos  present  on  right  side.  Tongue  extremely  unsteady,  protruded  in  ataxic 
jerks ;  lips  tremulous,  fails  to  whistle  ;  phonation  luiimpaired,  sings  well  without 
any  tremor  of  voice  ;  deglutition  unaffected.  The  right  pupil  is  much  the  larger, 
but  both  act  to  light  and  accommoilation. 

May  13,  188.3. — Passes  restless  nights,  laughing  incessantly  in  a  cliildisli  fashion, 
or  bursting  into  pitialde  lamentations  under  deluded  notions  respecting  her  home. 
Has  most  exalted  notions  respecting  her  personal  attractions ;  usually  speaks  of 
herself  in  the  third  person — "Mrs.  R.  has  had  a  good  dinner,  tliank  you  ;  Mrs.  R. 
is  a  beautiful  woman  ;  yes,  she  is  a  channing  person." 

June  6. — Suddenly  showed  loss  of  power  on  the  left  side  of  body,  a  condition 
preceded  by  excitement ;  the  paralysis  was  not  ushered  in  by  con^nilsion,  nor 
accompanied  by  loss  of  consciousness ;  the  leg  is  more  paralysed  than  the  arm ; 


TABETIC   SYMPTOMS    IN    GENERAL    PARALYSIS.  ^7& 

reflexes  are  acute  as  formerly,  but  there  is  no  apprecialjle  clouos  ;  she  grinds  her 
teeth  continuously.     The  right  pupil  is  still  the  larger  of  tlie  two. 

Aug.  20. — Her  gait  is  now  much  impaired,  an  unsteady  jog-trot— and  ankle- 
clonos  is  again  produced  in  right  foot.  There  is  marked  tremor  of  tongue,  lips 
and  facial  muscles,  and  constant  grinding  of  teeth,  even  during  conversation. 
Voice  is  tremulous,  and  raised  in  pitch.  Exhi))its  a  peculiar  state  of  double 
consciousness — thus,  in  crying  aloud  and  disturbing  other  patients,  she  immedi- 
ately rebukes  herself  by — "Mrs.  R.,  hold  your  tongue  !"  Again  becoming  noisy 
and  complainmg,  she  interrupts  herself  with — ' '  Be  quiet,  Mrs.  R. ,  you  are  the 
noisiest  child  in  tlie  house  !  "    Ocular  examination  gives  the  following  results  :— 

Size  of  pupils,  -^'  mm. ;  no  opacities  of  lens,  no  adliesions,  &c. 

Both  contract  and  dilate  actively  and  normally  to  light;  they  are  extremely 
mobile  iinder  emotional  excitation. 

Movements  with  accommodation,  are  normal. 

Dilatation,  on  cutaneous  stunulation,  is  scarcely  appreciable. 

Visual  acuity  =  Reads  Jaeger  No.  1  slowly  and  with  effort,  No.  2  with  fair  ease. 
Snellen  '5  at  12  inches  distance,  and  No.  5  at  3  metres. 

Optic  discs  normal  to  ophthalmoscopic  examination. 

Ai^ril  10,  1S84. — Bedridden;  both  limbs  held  stiff  and  rigid  by  voluntary  effort; 
knee-jerk  is  now  absent  in  the  right,  but  present  in  left  leg;  no  ankle-clonos. 
There  is  now  profound  dementia;  she  is  vaeant  in  aspect,  rarely  speaks,  but  often 
cries  aloud  in  a  frightened  voice. 

About  ten  months  later  it  is  noted  : — Sinking  rajjidly — when  approached,  or  any 
movement  near  her  occurs,  she  opens  her  mouth  instinctively  like  a  young  bii'd ; 
never  uses  her  hands,  although  they  show  no  contractures  or  clones — the  muscles 
are,  however,  greatly  wasted.  Both  legs  are  becoming  stiff  from  assumed  flexion — 
not  contracture ;  knee-jerks  are  wholly  abolished ;  plantar  reflex  greatly  diminished 
in  right  and  absent  in  left  foot.  Cutaneous  sensibility  almost  abolished  on  both 
sides,  especially  the  left.  Right  pupil  double  the  size  of  the  left;  both  remain 
almost  fixed  to  a  concentrated  beam  of  light ;  accommodative  movements  are  very 
limited  in  range,  and  sluggish.  She  swallows  only  with  the  greatest  difficulty, 
retaining  the  bolus  of  food  long  in  the  mouth. 

She  is  terribly  emaciated ;  looks  up  when  called  by  name,  and  opens  her  mouth 
loidely ;  is  extremely  timid,  shruiking  away  when  touched.  Died  February 
23,  1885. 


Knee-jerk  Abolished  or  Much  Impaired. — We  see  by  the  table 

given  above  that  fifteen  cases,  or  34  per  cent.,  exhibited  an  abolition  of 
the  knee-jerk  or  its  very  notable  impaii-ment.  Of  the  ten  cases  in 
which  the  knee-jerk  is  abolished,  on  one  or  both  sides,  five  cases  are 
notable  for  a  brisk,  elastic  walk,  yefc  all  present  serious  oculo-motor 
paralysis;  whilst  of  the  remaining  five,  the  gait  is  noted  as  being 
stiff  and  waddling ;  swaying,  staggering,  and  leaning  to  right  side ; 
stiff,  slow,  swaying ;  and  two  others  stiff.  In  all  these  latter  the 
pupils  are  likewise  fixed  to  their  usual  reflex  stimuli.  With  one 
exception  only,  the  deep  reflexes  when  impaired,  abolished,  or  in- 
tensified, were  accompanied  in  all  cases  by  irido-motor  paralysis ;  but 
the  latter  condition  was  often  found  advanced  with  a  perfectly  normal 


280  GENERAL    PARALYSIS, 

reaction  of  the  knee-jerk.  Just,  therefore,  as  we  may  find  the 
association  of  an  elastic,  easy  gait,  or  of  a  spastic  or  paretic  gait,  with 
exalted  deep  reflexes  and  advanced  intra-ocular  paralysis ;  so,  on  the 
other  hand,  we  may  encounter  the  association  of  a  normal  gait,  or  of  a 
paretic  or  tabetic  gait,  with  an  abolition  of  the  deep  reflexes,  and  like 
irido-motor  troubles.  The  tabetic  gait,  occasionally  associated  with 
this  absence  of  the  knee-jerk,  is  peculiarly  disorderly,  hurried,  spas- 
modic, and  insecure ;  the  legs  are  jerked  forwards,  the  feet  planted 
wide  apart,  and  the  heels  brought  down  with  considerable  force ;  there 
is  often  a  tendency  to  propulsion ;  the  patient  sways  from  side  to  side 
or  falls  when  the  eyes  are  closed  and  feet  approximated,  or  makes 
tottering  efforts  to  secure  his  equilibrium.  The  case  of  //.  U.,  given 
here  in  detail,  indicates  how  such  symptoms  may  entirely  disappear  and 
be  replaced  by  those  of  another  system-disease  of  the  spinal  cord. 

H.  U,,  aged  thirty,  a  married  woman  without  family,  was  admitteJ  in  October, 
1S8.3,  suffering  from  depression,  exhibiting  great  apathy  and  reticence,  refusing 
food,  and  passing  sleepless  nights.  Her  family  history  was  obscure.  It  was 
ascertained  that  the  patient  had  suffered  much  privation  of  late. 

On  her  admission  she  spoke  occasionally,  her  remarks  being  rational ;  but  she 
soon  lapsed  into  apathy  again,  assumed  a  stolid  expression,  and  was  reticent. 
Her  memory  was  found  to  be  very  defective.  The  pupils  measured  #  mm. ;  the 
light-reflex  was  abolished  in  both  eyes ;  consensual  movements  were  absent ; 
accommodative  movements  were  normal;  dilatation  upon  cutaneous  stimulation 
■was  abolished.  She  read  No.  1  Jaeger  slow^ly  and  at  a  fair  distance;  visual 
acuity  =  Snellen  §.  Appreciation  of  colour  normal.  She  was  unsteady  and 
tottering  in  gait,  swayed  much,  and  could  not  close  her  eyes  without  falling ;  nor 
could  she  walk  along  a  straight  line.  Lying  on  her  back,  she  could  resist  fairly 
well  an  effort  to  extend  her  limbs.  The  grasping  power  in  both  hands,  measured 
by  the  dynamometer,  did  not  exceed  4  kilos. 

During  the  first  month  of  her  residence,  she  remained  much  depressed  and  hea\-y, 
but  was  less  reticent.  She  became  easily  fatigued  upon  slight  exertion.  The 
oculo-motor  troubles  were  well  marked,  the  pupils  being  rigidly  fixed  to  a  con- 
centrated beam  of  light  showing  a  tendency  to  sliriht  dilalatlon  upon  sustained 
illumination  of  the  fundus.  She  read  Snellen  '6  at  50  cm,  with  ease.  The  follow- 
ing electric  reactions  were  noted  : — 

K.M.C.  A.M.C.  K.B.C.  A.B.C. 

Deltoid,           .         ,         .     12  26  Nil  at  50  Nil  at  50 

Pectoralis  major,    .         .     .34  22  ,,  ,, 

Supinator  longnis,  .         .     IS  26  „  ,, 

Biceps,  ....     14  34  ,,  ,, 

The  pectoralis  major  showed  the  R.D.  on  both  sides. 

Urine  =  sp,  gr.  1020;  no  albumen,  sugar,  or  deposits.  Heart  normal,  free 
from  briut. 

StiJt.  3,  1S83. — A  crop  of  herpetic  vesicles  has  formed  over  the  supraorbital 
branches  of  the  fifth  ner\-e  on  the  right  side.  The  parts  are  tumid,  the  conjunc- 
tiva mjccted,  and  there  is  "  shooting  pain  "  over  brow  and  hairy  scalp. 


TABETIC    SYMPTOMS — CASE    OF    II.    U.  281 

Nov.  14. — Much  depressed  and  agitated;  asks  for  her  husband,  and  bursts  into 
tears;  the  herpetic  eruption  has  disappeared.  She  sways  much  during  equilibra- 
tion ;  her  gait  is  unsteady,  and  tiic  lindis  are  thrown  about  in  the  disoi-derly  style 
characteristic  of  tlie  tabetic  subject.  Ataxy  of  the  upper  limits  is  very  notable  on 
endeavouring  to  thread  a  needle. 

Nuv.  IS. — A  sudden  convulsive  seizure  occurred  this  evening,  followed  by 
transient  right  hemiplegia  and  hemianesthesia;  the  reflexes  v;ere  normal.  She 
now  lies  in  a  state  of  stupor,  associated  with  great  depression ;  mouth  full  of 
frothy  saliva ;  she  resists  feeding,  and  does  not  sleep  well.  A  notable  degree  of 
corneal  opacity  has  remained  since  the  herpetic  attack. 

Nov.  20. — The  day  following  the  stroke  she  uttered  just  one  word,  but  has 
remained  mute  ever  since.  Has  been  fed  regularly  by  the  funnel.  Sensibility  has 
fully  returned  to  the  limbs. 

Nov.  24. — In  a  state  of  wild  delirious  excitement,  dominated  by  the  one  idea  of 
terminating  her  life  by  her  own  hands ;  made  a  most  desperate  attempt  to  secure 
a  knife,  and  piteously  implored  a  nurse  to  give  her  one. 

Nov.  26. — Acute  excitement  continues,  with  intense  restlessness ;  endeavours  to 
undress,  and  fling  herself  into  the  fire. 

Dec.  1. — Has  now  lapsed  into  a  state  bordering  on  imbecility,  associated  wdtk 
much  hysteric  excitement  and  general  mental  exliaustion.  Her  face  at  times 
beams  with  delight,  or  she  glares  vacantly  before  her,  giving  utterance  to  a  flow 
of  delirious  ideas  indicative  of  a  grandiose  state  of  mind.  Articulation  is  tremu- 
lous, syllabic,  explosive,  hesitating,  and  indicative  of  grave  implication  of  lips  and 
tongue — especially  the  labial  muscles.  There  is  a  distortion  of  facial  symmetry 
at  tunes,  ahnost  amounting  to  a  grimace  or  a  hideous  grin;  her  eyelids  quiver 
greatly. 

Dec.  18. — Aspect  like  that  of  a  general  paralytic,  beaming  and  ecstatic ;  enuncia- 
tion most  difficult,  speech  explosive  ;  always  applies  her  fingers  to  her  mouth  to 
steady  her  lips  wliilst  sjieaking  ;  there  is  much  mental  vacuity.  Her  gait  is  more 
steady,  still  tabetic,  comes  down  heavily  upon  the  heel ;  knee-jerk  exaggerated  in 
Ijoth  Ihnbs  ;  no  clonos. 

Jan.  12,  18S4. — Mental  distress  much  alleviated  of  late  by  chloral  in  conjunction 
with  bromide  of  sodium.  Still  has  a  happy,  beamuag  but  imbecile  look,  and  a 
childish  simpering  manner.  Labial  articulation  excessively  difficult ;  lingual  less 
so  ;  great  tremor  of  voice,  but  phonation  unimpaired  as  regards  pitch  and  timbre. 
Is  conscious  of  failing  vision  in  her  right  eye.  Knee-jerks  still  exaggerated ;  gait- 
much  less  notably  tabetic. 

Jan.  19. — An  attack  of  right  hemiplegia,  involving  arm  and  leg  complete!}',  and 
associated  with  aphasia ;  no  facial  asymmetrj'^ ;  complete  hemianesthesia ;  reflexes 
as  last  noted. 

April  10. — Another  attack  of  right  hemiplegia  on  the  lOtli  of  March  has  now 
left  her  bedridden,  speechless,  helpless,  and  apathetic.  Her  legs  are  tiexed  upon 
the  thighs  and  the  thighs  upon  the  abdomen,  but  can  be  fully  extended ;  right 
arm  shows  commencing  rigidity,  resists  flexion  strongly,  and  then  elbow-clonos 
arises  ;  wrist-clonos  readily  induced  on  the  same  side.  Knee-jerk  on  right  side  is 
extremely  exalted ;  slight  ankle-clonos  ;  deep  reflexes  of  left  leg  are  brisk  but 
less  marked ;  plantar  reflexes  acutely  exaggerated.  There  is  no  marked  vaso- 
motor or  trophic  change  in  the  skin  and  little  muscular  atrophy. 

May  5. — Now  sits  up  in  a  low  arm-chair  ;  is  fatuous  and  vacant ;  makes  sudden 
darts  forwards  in  a  stooping  attitude,  or  attempts  progression  on  lier  hands  and 
knees ;  can  just  support  herself   with  a  little   assistance,   but   is  tottering  and 


282  GENERAL    PARALYSIS. 

slovenly  in  gait,  lier  feet  are  kept  wide  apart  or  rotate  helplessly  outwards.  The 
right  leg  is  free  from  contractures ;  tlie  vastus  contracts  upon  percussion ;  the  knee- 
jerk  is  now  normal;  the  plantar  reflex  excecilingly  dulled;  no  clonos,  back-tap,  nor 
hamstring-jerk.  The  left  leg  shows  well-marked  clasp-knife  rigidity,  and  the 
knee-jerk  is  brisk  ;  sensation  in  both  soles  mucli  impaired.  The  skin  is  cold  and 
livid,  especially  over  left  foot.  The  right  arm  is  contracted  strongly  at  elbovr, 
semi-flexed  and  pronated  ;  exhibits  triceps-reflex  and  elbow-clonos ;  wrist  con- 
tracting, lield  rigidly,  and  fingers  bent  upon  palm.  The  left  arm  is  uncontracted, 
and  sliows  nothing  abnonnal  beyond  greatly  impaired  sensibility  as  in  the  opposite 
member.  Cutaneous  sensibility  remains  normal  only  over  the  face.  Swallows 
with  much  difficulty  and  spluttering.  The  sphincters  of  bladder  and  bowel  are 
paralysed.     Sense  of  smell  appears  unimpaired  ;  but  hearing  is  defective. 

June  30. — Has  just  recovered  from  a  series  of  strong  convulsive  seizures.  The 
right  arm  is  rigid,  flexed,  and  slightly  pronated;  it  can  be  forcibly  extended; 
there  is  no  clasp-knife  phenomenon,  but  slight  triceps-reflex.  All  the  extensors  of 
the  arm  contract  upon  percussion.  The  wi'ist  is  bent  at  right  angles  to  the  arm  ; 
fingers  and  thumb  flexed  tightly  on  palm.  The  left  arm  can  be  fully  extended, 
l)ut  is  usually  flexed  and  pronated  ;  reflexes  absent ;  no  affection  of  the  hand,  the 
fingers  move  freely,  and  are  kept  constantly  in  her  mouth.  She  fails  to  use  the 
right  arm  at  all,  but  resists  strongly  with  the  left ;  there  is  little  special  wasting, 
both  forearms  4  inches  below  olecranon  measure  6f  inches  around.  Epigastric 
and  hypogastric  reflexes  exalted.  The  legs  are  flexed  on  abdomen,  but  both  can  be 
freely  extended  ;  the  left  becoming  sUglitbj  fixed  in  a  sort  of  clasp-knife  extension 
i?ery  temporarily.  In  l)oth  legs  the  knee-jerk  is  notably  lessened,  and  only 
elicited  by  very  forcible  percussion.  Quadriceps  percussion-wave  is  present ; 
no  ankle-clonos  on  right,  but  a  very  slight  tendency  to  it  on  the  left  side ;  constant 
involuntary  twitchings  of  foot  and  toes  prevail ;  muscles  flabby,  but  not  specially 
wasted.  Plantar  reflexes  are  now  excessive,  pricking  the  soles  causes  convulsive 
jerhings  and  withdrawal ;  but  no  complaint,  movement,  or  attempt  at  withdrawal 
occurs  upon  pricking  the  calf  of  the  legs  or  thighs.  She  appears  only  to  appre- 
ciate irritation  of  the  skin  of  the  face.  She  constantly  grinds  her  teeth,  and  for 
two  weeks  past  has  invariably  opened  her  mouth  widely  upon  bringing  any  object 
near  her,  or  upon  touching  her  cheek  or  lips  ;  sioalloivs  ivell  and  rapidly.  She  lies 
perfectly  mute,  smacking  her  lips  and  incessantly  rolling  her  tongue  about,  and 
sucking  her  fingers;  bowels  greatly  constipated.  The  right  pupil  is  now  the 
larger,  and  both  are  dilated.     Died  November  27,  1SS4. 

Microscojnc  Examination  of  Spinal  Cord — Lumbar  Cord. — Anterior  columns 
exhibited  a  very  small  wedge-shaped  tract  of  sclerous  tissue  close  to  anterior 
commissure  ;  elsewhere  and  along  whole  of  anterior  root-zone  the  structure  was 
healthy,  beyond  some  proliferation  of  the  spider-cells.  The  lateral  columns  were 
healthy,  beyond  showmg  on  the  right  side  a  few  closely -aggregated  vessels,  with 
small  lumen  and  thickened  walls,  near  the  centre  of  the  column.  In  the  posterior 
columns,  however,  the  structure  was  coarsely  vascidar,  the  vessels  crowded  around 
by  spider-cells,  forming  coarse  tracts  along  median  raphe  and  posterior  commissural 
zone,  spreading  from  side  to  side  across  tliis  latter  region  within  and  in  front  of 
the  posterior  ground-fibres.  The  root-zone  and  peripheral  zone  of  these  columns 
had  escaped  implication.  Anterior  and  posterior  cornua  were  free  from  obvious 
lesion. 

Domal  Cord — Anterior  columns  appeared  iiitact  ;  the  lateral  columns  exliibited 
great  vascularity  of  their  central  part,  with  abundance  of  spider-cells,  especially 
on  left  side.     Posteriorly  the  columns  of  GoU  were  normal,  but  those  of  Burdach 


TABETIC,  SYMPTOMS — CASE  OF  II.  U.  283 

betrayed  much  coarse  vascularity  near  the  commissural  zone,  with  numerous 
spider-cells  distributed  parallel  to  the  raph6  and  along  the  ribands  of  Burdach. 
Clarke's  columns  showed  perfectly  healthy  cells,  and  the  anterior  and  posterior 
cornua  with  the  emergent  roots  were  normal.  The  central  canal,  as  elsewhere, 
was  crowded  with  leucocytes. 

Cervical  Cord. — Here  the  anterior  columns  and  l)oth  cornua  were  also  found  intact. 
In  the  right  lateral  column,  liowever,  a  deep-stained  sclerosed  area  lay  internal 
to  the  direct  cerel^ellar  tract,  extending  almost  as  far  forwards  as  the  antero- 
external  angle  of  the  cornu.  The  nerve-fibres  were  much  obscured  by  the 
extraordinary  development  of  the  spider-cells,  which  were  profusely  scattered 
throughout  the  whole  of  the  crossed  pyramidal  tract,  surrounding  numerous 
enlarged  blood-vessels.  Much  finely  punctated  tissue  was  seen  here,  but  no 
amyloid  bodies.  The  left  lateral  column  was  normal  in  all  respects,  except  that  a 
slight  increase  of  its  connective  indicated  a  little  unusual  depth  of  staining — a 
generally  dilated  state  of  its  vessels,  and  a  larger  supply  than  usual  of  its  spider 
elements. 

The  posterior  columns  exhibited  well-marked  changes  as  in  the  other  regions  ; 
coarsely-distended  vessels  with  deeply-stained  spider- cells  formed  a  notable 
feature  in  a  large  patch  of  sclerous  tissue,  just  at  the  junction  between  the 
columns  of  GoU  and  Burdach,  and  also  along  the  posterior  connnissural  zone. 
Such  changes  were  most  marked  on  the  left  side. 

Hypoglossal  Fegion  of  Medulla. — Both  hypoglossal  convolutes  were  degenerated 
on  either  sides  ;  their  nerve-cells  were  shrunken  and  diseased,  and  surrounded  by 
numerous  colloid  bodies  ;  the  emergent  root-fibres  were  notably  varicose.  The 
vagal  nuclei  exhibited  many  minute  degenerate  cells  or  their  disintegrated  relics. 
The  ascending  root  of  the  fifth  nerve  was  degenerated  in  its  posterior  two -thirds, 
but  the  olivary  and  its  arcuate  series  of  fibres  did  not  appear  implicated.  Another 
notable  site  of  degeneration  was  the  solitary  fasciculus  (f.  rotundus).  The  floor  of 
the  fourth  ventricle  was  covered  by  little  heaps  of  cell-growth,  giving  rise  to  its 
sand-papery  aspect  (graniilar  ependyma). 


Bladder. — It  is  at  this  period  that  urinary  troubles  arise,  and 
cause  much  anxiety  to  the  guardians  of  the  paralytic  patient.  When 
spinal  symptoms  have  fully  developed  themselves  and  the  lumbar  cord 
is  known  to  be  involved,  the  patient  is  never  secure  from  possible 
retention  of  urine,  which,  if  not  relieved  by  catheterism,  may  lead  to 
a  ruptured  bladder ;  an  accident  frequent  enough  as  to  be  a  source  of 
real  anxiety,  when  large  numbers  of  such  paralytic  cases  are  massed 
together  in  asylums. 

In  the  earliest  period  of  the  disease,  retention,  or  incontinence, 
may  occur,  but,  as  a  rule,  as  a  transient  condition  only ;  and  at  this 
time  the  patient  is  sufficiently  conscious  of  his  state  to  draw  the 
medical  attendant's  notice  to  the  point. 

Retention  may  occur  from  spasmodic  contraction  of  the  sphincter 
urethra'.,  due  to  irritation  of  the  lumbar  cord,  a  loaded  and  torpid 
bowel  being  a  most  frequent  starting-point  for  such  troubles.  It  may 
be  due,  on  the  other  hand,  to  the  presence  of  a  chronic  cystitis  and 


'2S4:  GENERAL    PARALYSIS. 

the  alkaline  urine  so  en^'ondored,  the  cystitis  having  a  neuropatliic 
origin  not  infrecjuently  in  changes  within  the  cord  and  sj)inal  nerves. 

RetGntion  far  more  frequently  is  an  indication  of  paralysis  of  the 
bladder;  it  is,  then,  usually  accompanied  hy  a  dribbling  away  of 
water,  which  fails  to  relieve  the  gradually  augmenting  accumulation, 
and  a  time  arrives  when  the  organ  becomes  dangerously  distended, 
and  no  expulsive  power  can  be  exerted  by  the  patient.  Such  patients, 
by  being  constantly  more  or  less  Avet  in  their  bedding  and  clothing, 
"would  readily  deceive  an  experienced  nurse.  The  condition  is  identi- 
cal with  that  induced  upon  section  of  the  spinal  cord  above  the  level 
of  the  anterior  and  posterior  roots  of  the  third,  fourth,  and  fifth  sacral 
nerves — the  sensory  and  motor  arcs  for  the  sphincter  iLrethro'.  Such 
section  withdraws  the  inhibitory  control  of  the  cerebrum,  thus  increas- 
ing the  reflex  activity  of  the  sphincter  (Landois*).  All  such  cases 
should  be  uniformly  treated  by  a  periodic  catheterism,  allowing  no 
great  accumulation  to  occur. 

A  still  more  dangerous  condition  arises  in  certain  cases,  fortunately 
somewhat  rare.  The  bladder  becomes  attenuated,  or  undei-goes  con- 
siderable fatty  degeneration,  as  the  immediate  result  of  s[)iual  disease 
— a  genuine  tropho-neurosis.  Nor  is  this  very  surprising  when  wc 
learn  from  the  results  of  autopsy  in  general  paralysis  how  extensive 
are  the  trophic  disturbances  which  other  organ.s,  and  especially  the 
■muscular,  undergo.  In  this  degeneration  the  muscular  coat  of  the 
bladder  especially  sutlers,  and  the  organ  may  be  ruptured  by  a  slight 
distending  force  when  aided  by  such  accidents  as  a  fall  or  a  blow,  cr 
even  powerful  expulsatory  efforts,  as  in  severe  vomiting. 

A  recent  convulsive  seizure,  or  an  apoplectiform  attack,  may  leave 
the  patient  subject  for  some  time  subsequently  to  paralytic  retention; 
and  in  our  treatment  of  a  case  of  this  nature  the  state  of  the  bladder 
should  be  almost  the  first  snl/ject  to  engage  our  attention,  f 

A  similar  condition  of  the  bladder  often  prevails  in  advanced  cases 
of  tubes,  and,  as  indicated  by  Dr.  Buzzard,  may  even  form  the  most 
prominent  symptoms  and,  like  gastric  crises,  or  optic  atrophy,  if  ataxy 
be  absent,  be  readily  regarded  apart  from  the  real  cause — "  I  have 
little  doubt  that  not  a  few  cases  of  atony  of  the  bladder  for  which  the 

*  Op.  ciL,  p.  G53. 

t  A  well-trained  medical  officer  with  many  paralytic  cases  under  liis  care  will 
never  fail  to  direct  the  nursing  staff  to  keep  a  record  of  all  such  cases,  and 
check  the  same  himself  by  daily  reference,  morning  and  evening,  to  the  wanler's 
report,  and  by  actual  examination  of  the  abdomen.  Even  under  the  strictest 
supervision  an  accident  may  still  occur  at  times,  as  in  the  cases  of  degenerated 
muscular  wall  of  the  bladder.  It  is,  liowever,  quite  inexcusable  for  any  such 
patient,  known  to  be  suflfering  from  paralytic  enuresis,  to  escape  examination 
night  and  morning. 


PAIiALVSES    FUOM    SPINAL    IMPLICATIONS.  285 

surgeon  is  consulted  are  examples  of  tabes,  with  the  hladder  trouble 
predominating."  *  Ai)avt  from  any  well-marked  spinal  paralysis, 
retention  frequently  occurs  as  the  result  of  simple  inattention,  the 
accompaniment  of  ])rofound  dementia,  with  which  there  is  often 
associated  a  diminished  reilex-excitability  of  the  bladder,  the  organic 
reflexes  corresponding  to  the  general  impairment  of  the  superficial 
spinal  retlexes.  There  is  not  only  the  diminished  excitntion  of  the 
spinal  centre  necessary  to  initiate  the  act,  but  the  patient  does  not 
feel  the  need  of  micturition.  It  is  found  necessary  in  our  asylum 
wards,  where  some  sixty  or  seventy  general  paralytics  are  often 
congregated,  to  keep  a  daily  and  nightly  record  of  all  such  inattentive 
cases,  and  of  all  bed-ridden  cases  alike. 

Enuresis. — Incontinence  of  urine  invariably  occurs  in  the  paralytic 
stage  of  this  affection,  as  in  all  cases  where  the  dementia  also  is 
advanced.  It  forms,  together  with  like  bowel  troubles,  the  daily 
source  of  trial  to  the  nurse — a  burden  which  may  be  considerably 
alleviated  by  tact  and  careful  observance  of  simple  rules  of  treatment. 

AVhilst  retention  is  produced  by  section  of  the  cord  above  the  level 
of  the  reflex  centres  of  the  sphincter  (above  the  third  sacral  nerve)  by 
removal  of  its  inhibitory  centre,  so  section  or  disease  on  a  level  with 
the  reflex  centres  produces  incontinence,  as  will  any  incompetence  in 
the  reflex  sensory  or  motor  arc.  It  must  be  remembered  that 
voluntary  impulses  passing  down  the  motor  tract  of  the  cord  do  not 
act  directly  upon  the  smooth  muscular  fibre  of  the  bladder,  but  they 
act  in  two  directions — (a)  onjthejsphincter  urethrse  or  its  motor  centre 
in  the  cord,  so  intensifying  the  reflex  contraction;  (6)  on  an  inhibitory 
centre  in  the  cord  above  the  reflex  apparatus,  which  antagonises  the 
latter  and  allows  the  sphincter  to  relax,  f 

The  necessity  for  continuous  care  and  change  of  bed-clothing  in  these 
wet  cases  is  emphasised  by  the  otherwise  certain  occurrence  of  bed- 
sores which,  in  these  debilitated  subjects,  become  a  formidable  compli- 
cation to  the  nurses.  The  irritation  of  the  skin,  by  its  constant 
soakage  in  urine,  develops,  moreover,  pajndar  eruptions  over  the  back, 
the  groin,  and  thighs,  which  are  abraded  by  the  patient's  hands. 

Bowels. — Another  troublesome  and  objectionable  condition  of  the 
later  stages  of  general  paralysis,  is  the  paralysis  of  the  anal 
sphincter,  which  results  in  such, frequent  incontinence  of  the  bowel; 
the  condition,  of  course,  is  at  once  recognised  on  introdixcing  the  finger 
per  rectum,  when  the  patency  and  want  of  tone  of  the  sphincter  is  very 
obvious.     As  is  the  case  with  the  bladder  and  sphincter  urethr£e,  the 

*  "Ou  little-recognised  phases  of  Tabes  Dorsalis  "  in  Diseases  of  the  Nervous 
Sy.'itcm.     Dr.  Buzzard,  1SS2,  p.  274. 
tLandois  and  Stirling,  op.  c'U.,  p.  654. 


286  GENERAL    PARALYSIS. 

cerebrum  can  voluntarily  contract  the  external  sphincter  ani,  or  can 
inhibit  its  contraction;  such  motor  fibres  descending  through  the 
cerebral  peduncles  to  the  lumbar  cord. 

The  centre  for  this  inhibitory  agency  is  stated  by  Masius  to  be  in 
the  optic  thalamus.  So  likewise,  energetic  voluntary  contractions  of 
the  levator  ani  and  sphincter  arouse  the  active  rectal  peristalsis  neces- 
sary to  initiate  defsecation,  by  bringing  the  excrementitious  mass  down 
into  the  rectum.  When  once  there,  it  creates  the  uneasy  feeling 
which  prompts  the  voluntary  inhibition  of  the  sphincter  ani,  and 
allows  the  mass  to  be  extruded.  Thus  the  act  of  defoscation  is  in 
every  way  similar  to  that  of  micturition,  it  being  really  a  reflex 
spinal  act  during  a  voluntary  inhibition  of  the  sphincter.  There 
is  the  reflex  loop  constituted  by  the  sensory  nerves  of  the  rectum,  and 
the  motor  nerve  of  the  sphincter  and  the  plexus  myentericus  inducing 
peristalsis ;  a  tract  for  voluntary  impulse  to  excite  conti'action  of  the 
sphincter ;  a  centre  in  the  cerebrum  for  the  inhibition  of  the  latter. 

Degenerative  changes  in  the  lumbar  cord  occasionally  give  rise  to 
the  complete  paralysis  of  the  anal  sphincter ;  much  more  frequently  is 
it  a  matter  of  sluggish  or  incomplete  reflex  of  this  muscle  than  of 
actual  paralysis,  as  well  as  a  defective  tonicity  which  has  been  much 
alleviated  by  the  apjilication  of  tannin  suppositories,  a  treatment  first 
recommended  by  Dr.  Robert  Lawson.* 

In  bed-ridden  cases  of  general  paralysis,  a  not  unusual  symptom  is 
that  of  frequent  alvine  evacuation  from  simple  increased  peristalsis, 
not  amounting  to  a  genuine  diarrhcea,  but  a  very  frequent  "  formed  " 
stool ;  at  times,  however,  the  stools  become  very  loose,  yet  without 
any  pyrexial  accompaniments,  and  due  apparently  to  centric  irritation 
of  the  vagus.  Epileptiform  seizures  in  general  paralysis  are  apt  to  be 
accompanied  or  followed  by  such,  but  are  then  watery  alvine  fluxes. 
Thus  in  the  case  of  R.  E.  P.,  severe,  continued  convulsions,  aff"ecting 
the  left  side  of  the  body  only,  were  associated  with  very  copious  and 
frequent  evacuations. 

A  similar  condition  has  been  noted  by  Dr.  Buzzard  in  certain  cases 
of  tabes,  and  which  he  regards  as  possibly  dependent  upon  irritation  of 
the  vagal  nucleus  in  the  medulla.! 

In  these  cases  the  flux  is  probably  the  result  of  paralysis  of  the 
splanchnics,  the  vaso-motor  nerves  of  the  intestines ;  and  to  the 
resulting  transudation  of  fluid  from  the  blood-vessels  into  the  bowel, 
with  the  accompanying  increased  j)eristalsis. 

*  "  Clinical  Notes  on  Conditions  incidental  to  Insanity,"  by  Robert  Lawson  and 
W.  Bevan  Lewis.     No.  1,  West  Riding  Asylum  Reports,  vol.  vi. 

t  Opldhalmopleri'ia  Externa  with  Tabes  Dursatis  (Dr.  Buzzard,  p.  200).  See  also 
case  described  by  the  same  writer  in  Diteases  of  Nervous  Si/stem,  p.  218. 


HAEMOGLOBIN    IN    THE    nLOOD    IN    GENERAL    PARALYSIS. 


287 


The  Blood  in  General  Paralysis.— A  diminution  of  hsemoglobin 

is  clearly  indicated  in  all  cases  of  general  paralysis  examined  by  us. 
The  corpuscular  richness  varied  considerably — in  fact,  from  75  to  12G 
per  hcemic  uoiit,  the  higher  register  pertaining  to  cases  where  maniacal 
excitement  prevailed.  No  connection  is  established,  however,  between 
mania  and  such  corpuscular  richness,  since  a  diminution  in  the  number 
of  red  corpuscles  is  quite  as  often,  and,  in  our  experience,  more 
frequently,  met  with  in  maniacal  conditions.  What  is  of  more  im- 
portance to  note  is  the  diminished  colorimetric  power  of  the  corpuscle, 
the  proportion  of  haemoglobin  varying  from  52  to  75  per  cent. 
Taking  into  consideration  the  corpuscular  richness,  we  find,  that  the 
absolute  deficiency  of  haemoglobin  gives  a  corpuscular  value  varying 
between  56  and.  89  per  cent.  The  accompanying  table  gives  the 
results  obtained  in  fifteen  cases  of  general  paralysis  at  diflferent  periods 
of  the  disease  : — 


Amount  or  Hemoglobin  in  the  Blood  in  Geneeal  Paralysis. 


• 

Heemoglobin. 

Red                     Vi 

Corpuscles.          Corj 

^hite 
uscles. 

Value  per 
Corpuscle. 

Per  cent. 

Per  heemic  unit.  Per  ha 

emic  unit. 

T.  G.     (July  24,  '87), 

70 

125 

40 

•56 

„        (Aug.    2,    „  ), 

72 

126 

40 

•57 

W.  W.  (Aixg.   5,    ,,  ), 

70 

124-6 

13 

•56 

„        (Nov.   S,    ,,  ), 

70 

108-8 

16 

•65 

T.  C.     (July  24,    „  ), 

60 

103 

60 

•58 

(Aug.   3,    „  ), 

75 

110 

50 

•68 

„        (Sept.  21,   „), 

63 

85 

40 

•74 

W.  A.  (Dec.  16,    ,,  ), 

58 

91-2 

20 

•63 

T.  W.    (Aug.  4,    ,,  ), 

"  52 

80 

30 

•65 

,,        (Sept.  29,    „  ), 

54 

75-6 

40 

•72 

J.  R.      (Nov.  9,    „  ), 

66 

102-4 

25 

•64 

S.  S.       (Oct.    9,    „  ), 

68 

100-6 

24 

•68 

J.  H.     (Dec.  16,    ,,  ), 

60 

86 

32 

•69 

J.  B.  S.  (Dec.  16,    „  ), 

70 

91 

22 

•76 

E.  E.     (Aug.   4,    „  ), 

62 

81-8 

50 

•76 

„        (Sept.  29,    „), 

70 

96-2 

32 

•72 

C.  W.    (Nov.   5,    „  ), 

64 

79 

20 

•SI 

J.  W.     (Dec.  16,    „  ), 

70 

78-4 

22 

•89 

G.  H.     (July  17,    „  ), 

68 

81-8 

20 

•S3 

T.  H.     (Oct.    9,    „  ), 

77-2 

25 

B.  W.    (Nov.  8,    „  ), 

64 

10 

... 

288  ALConoLic  insanity. 

In  the  cases  of  7?.  A'.,  ./.  B.  S.,  J.  A.,  as  of  several  others  not  noted 
ill  the  above  list,  the  blood  flowed  with  great  sluggishness,  rendering 
its  collection  by  the  usind  means  extremely  ditKcult.  In  such  cases 
the  surface!  Avas  cold  and  very  pallid,  the  vessels  being  undoubtedly  in 
a  state  of  si)asm,  and  insldutaneous  couz/xlation  was  prone  to  occur,  ere 
the  blood  could  be  withdrawn  by  the  pipette;  no  inflammatory 
complication  existed  in  these  subjects.  Similar  cases  of  exti-emely 
slow  oozing  blood  exhibited,  on  the  other  hand,  abnormal  delay  in 
coagulation. 

ALCOHOLIC   INSANITY. 

Contents. — Alcoliolism  and  Age— Susceptibility  at  Certain  Develoiimental  Phases  — 
Adolescent  Period  (F.  S.) — Prevalence  of  Impulse— Influence  of  Sex,  Heredity, 
Epilepsy,  Cranial  Injui-y,  Ancestral  Intemperance— Anomalies  of  Systemic  and 
Visceral  Sensation— Aural  Hallucinations  (J.  J^)- Delusions  of  Susjiiciou — 
Optimistic  Delusions— Clinical  Forms  of  Alcoholism — Mania  a  Potu — Amblyopia 
Cutaneous  Anaisthesias — llelapses— Case  of  W.^Y.- -Homicidal  Impulse  (G.  S.) — 
Chronic  Alcoholism— Physiological  Effects  of  Alcoliol— Evolutionary  Period- 
Mental,  Sensorial,  and  Jlotorial  Symptoms  (J.  J^.) — Amnesic  Forms  (J.  F.)— Con- 
ditions of  Mental  Pievivability  (M.  H.  L.)— Delusional  Forms  (T.  S.)— Instances  of 
"Environmental  Resistance" — Visceral  Illusions- The  Epigastric  Voice— Vari- 
ous Illusory  States  (E.  A.  F.) — Evolution  of  Psychical  Phenomena— The 
Nervous  Discharge — Hallucination  as  Determining  Morbid  Ideation — Augmented 
Specific  Eesistance— Sensory  Anomalies— Motor  Enfeeblement  (J.  P.)- Twitch- 
ings,  Tremors,  Stolidity  —  Eeaction-Time  iu  Alcoholism  —  Muscular  Spasms 
and  Cramps— Oculo-Motor  Immunity — Nystagmus  —  Epileptiform  Attacks — 
Hemiplegiie  (T.  P.  and  J.  C) — Classification. 

Alcohol  is  a  fertile  source  of  nervous  disease,  and  its  implication  of 
the  nervous  centi'es  is  so  general  and  far-reaching,  that  the  resultant 
symptoms  are  of  most  protean  nature ;  no  poison,  except  the  A'irus  of 
syphilis,  plays  so  extensive  a  role  in  the  morbid  affections  and  degener- 
ations of  the  tissues,  nervous  or  non-nervous.  Yet,  as  regards  its 
effects  upon  the  nervous  system,  it  is  possible  to  trace  its  march  with 
a  fair  degree  of  accuracy,  and  to  classify  into  definite  groups  the 
victims  of  over-indulgence  in  accordance  with  the  degree  of  implica- 
tion— the  depth  to  which  nervous  dissolutions  have  attained.  Ere  we 
classify,  however,  the  more  or  less  distinctive  forms  of  such  aflfections, 
it  will  be  well  to  glance  generally  at  the  insanity  induced  by  alcoholic 
indulgence;  and  for  this  pui'pose  we  have  inquired  into  the  history  and 
antecedents  of  4G4  patients,  whose  insanity  was  attributable  to  excessive 
drinking;  of  which  number  344  were  males.  And,  in  the  first  place,  who 
are  the  subjects  most  liable  to  thejjdifferent  forms  of  alcoholic  neurosis? 

Ag'e. — The  period  of  life  is  here  an  element  which  it  is  important 
to  examine.  Were  we  acquainted  with  the  actual  amount  of  excessive 
drinking  in  the  community  at  large,  and  at  different  ages,  as  also  with 
the  percentage  of  those  who  succumbed  to  insanity  as  the  direct  result 


ALCOHOL    AND    TIIIi:    ADOLESCENT    PERIOD.  289 

of  drink,  and  tlu;  time  roquiri'd  for  excessive  drinking  to  evolve  such 
results,  we  might,  by  a  comparison  of  asylum  statistics,  ensure  some 
degree  of  accuracy  in  estimating  the  incidence  of  alcohol  as  a  causative 
agency  of  insanity.  Such  absolute  data  are  at  present  out  of  our 
reach  ;  and  we  must,  consequently,  rest  content  with  the  ascertained 
history  of  our  asylum  community  without  reference  to  the  sane.  Nor 
is  this  altogether  devoid  of  immediate  iitility,  since  our  object  is  not  so 
much  that  of  ascertaining  the  exact  incidence  of  alcohol  in  insanity,  as 
to  extract  the  characteristic  features  of  the  neurosis  which  alcohol 
induces.  Every  period  of  life  shows  its  proclivities  towards  special 
diseases ;  and  the  action  of  toxic  agencies  demonstrates  the  peculiar 
susceptibility  of  the  nervous  system  to  their  operation  at  certain  stages 
of  its  evolution.  Some  such  law  would  appear  to  govern  the  origin  of 
mental  affections  induced  by  alcoholic  indulgence,  since  these  are 
certainly  far  more  prone  to  occur  between  the  ages  of  twenty-five 
and  thirty,  and,  again,  from  thirty-five  to  forty-five,  than  at  other 
periods  of  life.  It  is  easy  to  assume  that  at  these  periods  of  life  the 
actual  number  of  excessive  drinkers  is  larger  than  at  other  times ;  at 
present  no  data  supporting  such  assumption  are  forthcoming,  nor  do 
we  see  any  reason  why  the  age  of  thirty  to  thirty-five  should  claim 
special  immunity.  It  must  be  remembered  that  this  age,  from  twenty- 
five  to  thirty,  is  one  peculiarly  characterised  by  intellectual  advance, 
as  contrasted  with  the  more  emotional  developments  and  expansion  of 
the  moral  nature  which  takes  place  during  adolescence. 

It  is  also  the  age  when  the  struggle  for  existence,  in  its  widest  sense, 
makes  itself  felt  upon  the  organism  in  fullest  force ;  it  is  not  the 
period  of  longing  and  yearning  for  activity,  for  plans  of  action  and 
castle-building,  but  it  is  peculiarly  the  age  of  active  being,  when  the 
mettle  of  the  man  is  tried,  and  his  weight  as  a  social  unit  fairly  esti- 
mated. It  is  upon  his  intellectual  advance,  which  at  this  epoch  is 
so  important  and  so  notable,  that  his  success  as  a  social  factor  largely 
depends ;  for  a  successful  life  is  the  outcome  now-a-days  of  a  well- 
balanced  adjustment,  and  hence  depends  on  a  highly  appreciative  and 
intelligent  recognition  of  complicated  relationships. 

It  is  a  period  when  feeble  and  indifferent  organisations  often  feel 
a  want  for  an  artificial  stimulus  to  goad  them  on,  and  many  succumb 
to  such  perilous  inducements  ;  and  it  is  peculiarly  a  period  when 
certain  inherited  neuroses  place  the  individual  at  a  disadvantage  in 
the  competition  of  life.  In  fact,  it  is  a  period  when  the  first  great 
swellings  of  the  intellectual  tide  make  themselves  felt  throughout 
the  whole  organism,  and  when  inherited  frailties,  coeval  in  their 
manifestation  in  parent  and  offspring,  assert  the  supremacy  of  the 
laws  of  periodicity  in  development.     All  such  nascent  developments 

19 


290  ALCOHOLIC   INSANITY. 

are  most  prone  to  early  decay  in  dissolutions  of  the  nervous  system ; 
and  upon  them  chiefly  appears  to  be  expended  the  full  force  of  those 
agencies  credited  with  the  proximate  causation  of  insanity.  Thus  it 
is  that  in  the  moral  and  emotional  developments  of  the  adolescent  epoch, 
sexual  and  alcoholic  excesses  tell  more  directly  upon  this  phase  of 
mental  life,  and  that  hysteric  forms  of  insanity  and  a  stunted  moral 
development  are  so  often  revealed  at  such  an  age.  In  like  manner, 
this  latter  epoch  of  intellectual  expansion  exhibits  the  earliest  eflects 
of  alcoholic  excess  as  inducing  reductions  in  the  intellectual  sphere, 
and  only  later  on,  as  profoundly  affecting  the  emotional  and  moral 
being  of  the  individual.  This  is  why  we  regard  age  as  an  important 
element  in  the  evolution  of  these  forms  of  alcoholic  insanity. 

F.  S.,  aged  twenty-five,  widower,  and  a  warehouseman.  When  admitted  he  had 
been  insane  for  six  weeks ;  had  been  very  wild,  rambling  in  speech ;  called  himself 
the  "Holy  One,"  the  "  Great  Physician."  Patient's  father  is  of  dull  intellect  and 
of  intemperate  habits ;  paternal  uncle  was  insane ;  patient  was  addicted  to  excessive 
drinking  from  the  age  of  fourteen  to  that  of  twenty-one,  remained  temperate  for 
two  years  subsequently,  and  has  again  relapsed  into  his  former  excesses.  Upon 
admission  he  exhibited  great  exaltation,  spoke  excitedly,  and  loudly,  giving 
expression  to  optimistic  delusions  ;  he  had  exalted  notions  respecting  his  muscular 
powers;  was  "perfect  in  body  and  mind,  and  surpassed  all  others  in  know- 
ledge and  skill;"  he  has  "a  perfect  knowledge  of  the  human  frame,  is  a  great 
physician,  and  can  cure  all  diseases. "  He  declares  that  he  can  ' '  easily  lift  half -a- 
ton,  and  has  often  raised  many  hundred  tons  aloft ;  all  England  will  become  his, 
ere  long;  is  possessed  of  enormous  wealth."  His  manner  is  abrupt,  but  he  is 
inclined  to  be  friendly  and  jovial ;  expression  flushed  and  excited  ;  pupils  widely 
dilated,  but  equal  and  of  normal  reaction ;  tongiie  shows  notable  and  extensive 
fine  fibrillar  tremor,  no  ataxic  jerks ;  articulation  is  unimpared  ;  the  reflexes  are 
normal ;  cutaneous  sensibility  is  unimpaired.  Patient  is  muscular  and  well 
nourished.     Examination  of  other  systems  proved  negative. 

In  a  fortnight  he  was  considerably  calmer  ;  the  same  liien-etre  was  manifest,  but 
he  was  so  far  reasonable  as  to  be  employed.  This  remission  lasted  but  two  weeks, 
and  he  relapsed  into  severe  maniacal  excitement,  in  which  with  every  varying 
mood,  from  abrupt  rudeness  to  jovial  humour,  he  maintamed  the  same  exalted, 
grandiose  notions.  His  habits  now  became  degraded  and  filthy  at  night,  and 
masturbation  was  practised. 

Six  months  after  admission,  excitement  continued  unabated,  he  was  insolent, 
threatening,  and  demonstrative.  Habits  of  masturhation  so  reijulsively  sliamcless 
and  open  that  the  liquor  epispasticus  was  aj^plied  locally,  and  chloral  with  bromide 
of  potassium  given  internally  with  only  temporarily  good  results.  These  habits 
kept  xvp  persistently  seemed  to  account  for  the  slow  progress  made  in  his  case, 
for  he  remained  twelve  months  in  the  asylimi  ere  the  excitement  abated  ;  even 
then  for  several  months  he  exhibited  an  imbecile  aspect,  laughed  umnoderately 
without  cause,  was  restless,  untidy,  senseless  or  irrelevant  in  his  observations, 
and  given  also  to  insane  gesticulation  and  grimace. 

Twenty  months  elapsed  ere  he  was  discliargeil  recoveretl. 

We  must,  as  before  hinted,  make  due  allowance  for  this  age  as  one 
offering  peculiar  inducements  to  heavy  drinking;  and  for  the  fact  that 


PREVALENCE    OF    IMPULSIVE    STATES.  291 

a  certain  period,  even  for  those  specially  predisposed,  must  elapse  ere 
alcoholic  excess  results  in  actual  mental  alienation  ;  but,  when  all  such 
factors  arc  allowed  for,  wo  still  think  the  evolutional  phase  of  this 
epoch  is  the  chief  reason  why  so  large  a  proportion  of  mental  cases  are 
attributable  to  alcoholic  excess. 

The  facts  as  given  in  our  statistical  Tables  ai-e  striking,  for  out  of 
344  males  suffering  from  one  or  other  of  the  forms  of  alcoholic  insanity, 
29  cases  alone  occur  between  the  ages  of  fifteen  and  twenty-five, 
whilst  as  many  as  52  occur  during  the  next  five  years,  or  87  up  to 
thirty-five  years  of  age ;  each  of  the  two  succeeding  quinquennial 
periods  of  life  claiming  some  50  victims  of  these  afi'ections. 

Predisposition. — The  subjects  of  alcoholic  insanity  admitted  into 
our  asylum  do  not  exhibit  any  unusual  degree  of  the  insane  heritage, 
the  proportion  of  hereditary  cases  not  rising  above  27  per  cent.,  and, 
consequently,  not  attaining  to  the  average  heredity  of  all  Jorms  of 
insanity  alike.  All  recurrent  cases  of  insanity  taken  together 
exhibit  a  far  higher  insane  inheritance  than  this.  If  we  now 
group  together  all  cases  of  insanity,  epilepsy  and  other  neuroses, 
occurring  in  the  family  history  of  these  insane  subjects,  as  also  all 
cases  of  ancestral  intemperance,  we  find  such  predisposing  elements 
present  in  37  "2  per  cent,  of  the  total  number  of  cases  of  male  patients. 
Where  ancestral  intemperance  was  the  sole  ascertained  predisposing^ 
cause,  it  was  almost  exclusively  limited  to  the  father,  and  in  no  case 
was  the  mother  addicted  to  this  vic'e.  Taking  a  history  of  insanity 
and  excessive  drinking  collectively,  we  find  such  present  in  the  case 
of  thirty-one  fathers  and  sixteen  mothers,  so  that  the  influence  of 
sexual  limitation  in  transmission  is  here  apparently  demonstrated. 

Nature  of  the  Attack. — Taking  first  the  344  males — maniacal 
excitement  prevailed  in  57*8  per  cent.,  of  which  over  26  per  cent,  are 
delusional  forms  of  insanity,  only  6"3  per  cent,  being  acute  maniacal 
states.  On  the  other  hand,  melancholic  dej)ression  prevailed  in  28 "7 
per  cent. ;  42  cases  were  attended  with  delusional  perversion,  28  were 
simple  melancholic  forms,  while  12  (or  3*4  per  cent.)  were  cases  of 
chronic  cerebral  atrophy.  The  maniacal  states  were,  therefore,  con- 
siderably in  excess  of  the  melancholic  forms  of  alienation,  in  fact, 
they  were  twice  as  numerous ;  whilst  pronounced  dementia  apper- 
tained to  a  small  section,  forming  only  8-4  per  cent,  of  the  whole. 

Taking  the  aggregate  of  344  cases  where  alcoholic  excess  preceded 
the  attack  of  insanity,  the  fii-st  important  fact  taught  us  by  a 
glance  over  our  statistics  is  the  essentially  imjndsive  nature  of  the 
afi'ection;  it  is  in  all  its  phases  a  COnvulsive  neurOSis.  Whether 
excitement  pi-evails,  and  the  disordered  propensities  exliibit  sudden, 
explosive  impulses;  or  whether  depression,  with  its  frequent  accom- 


292  ALCOHOLIC    INSANITY. 

pauiment  of  hallucination,  predominates,  and  painfully  pent-up  feeling, 
or  suddenly-aroused  terror  results  in  determined  violence  to  self 
or  others ;  or,  lastly,  whether  they  are  forms  of  mental  fatuity 
Avith  depression — the  all-important  feature  to  be  borne  in  mind  is 
this  prevailing  convulsion  of  conduct.  The  maniacal  forms  exhibit 
such  impulsiveness,  nut  so  niucli  in  attempts  at  self-injury  as  in 
a  dangerous  aggressiveness  to  others,  in  destructive  fits,  in 
sudden,  treacherous,  and  often  brutal  violence,  a  tendency  which 
renders  these  lunatics  a  peculiarly  dangerous  element  in  our 
asylum  communities;  about  68  per  cent,  were  thus  returned  as 
dangerously  impulsive  toward  others.  The  melancholic  victim, 
however,  is  more  likely  to  turn  his  hand  against  himself;  one  half 
of  such  cases  at  the  lowest  estimate  being  dangerously  SUicidal. 
The  tendency  to  suicidal  and  homicidal  impulse  is  high  even  in 
advanced  forms  of  dementia,  and  it  is  a  noteworthy  feature  that  in  those 
cases  of  dementia  which  are  dependent  upon  chronic  alcoholic  cerebral 
atrophy,  suicidal  and  homicidal  impulse  reaches  its  climax  of  fre- 
quency; as  many  as  66'6  per  cent,  of  such  forms  being  determinedly 
suicidal,  and  83'3  per  cent,  being  dangerously  aggressive.  The 
intrinsically  impulsive  outbursts  of  alcoholic  insanity,  whether  mania, 
melancholia,  or  dementia  prevail,  should  never  be  forgotten  by  those 
dealing  with  the  insane. 

Taking  into  account  only  the  male  alcoholics,  age  apparently  had 
no  distinct  influence  over  the  character  of  the  mental  symptoms,  one 
half  the  cases  of  mania,  as  of  melancholia,  occurring  up  to  forty  years 
of  age,  and  the  other  half,  subsequently.  We  may  anticipate  the 
largest  number  of  maniacal  or  melancholic  patients  to  be  between 
twenty -five  and  thirty  years  of  age,  and  the  next  largest  proportion 
to  be  in  the  quinquennial  periods  immediately  preceding  and  following 
the  age  of  fox'ty.  A  considerable  rise  in  the  number  of  melancholic 
cases  amongst  such  a  class  of  insane  inebriates  again  occurs  at  the  age 
of  fifty  to  fifty-five,  and  a  similar  rise  in  maniacal  ailments  from  fifty- 
iive  to  sixty  years  of  age.  We  may,  thei-efore,  conclude  that  although 
certain  periods  of  life  are  especially  prone  to  the  development  of  alco- 
holic insanity,  such  as  the  ages  of  twenty-five  to  thirty,  from  thirty-five 
to  forty,  and  again  towards  forty-five,  maniacal  and  melancholic  forms 
appear  in  the  same  relative  frequency  at  these  epochs  of  life. 

If  we  attempt  to  explain  why  the  form  of  insanity  should  assume 
in  one  case  the  maniacal  and  in  the  other  the  melancholic  type,  we 
are  able  to  afl'ord  but  little  explanation  and  that  purely  of  a  negative 
character.  Thus  age  is,  as  just  noted,  an  indifferent  element  in  this 
connection ;  in  like  manner  inheritance  cannot  be  stated  to  have 
any    very    definite    influence    in    either   direction ;    excitement    does, 


IIALLUCIXATIONS    AND    DELUSIONS.  293 

however,  })rccloniinate  in  liereditary  insanity  ;  Ijut  tlie  propovtionato 
number  of  maniacal  to  depressed  cases  appears  still  greater  among 
those  who  afford  the  history  of  ancestral  intemperance.  Epilepsy  and 
other  neuroses  also  appear  to  be  wholly  indifferent  factors.  Then 
again,  as  regards  sex,  it  is  noted  that  melancholic  states  are  to 
maniacal  proportionately  more  frequent  in  male  than  in  female 
inebriates,  being  but  one-fourth  in  women  and  one-half  in  men.  Sex, 
therefore,  does  appear  to  lend  some  influence  in  predisposition  to  the 
one  or  the  other  type  of  insanity.  Lastly,  recurrent  seizures 
throw  no  light  upon  the  subject,  depression  and  excitement  occurring 
with  about  the  same  relative  frequency  in  relapsed  cases  (mania, 
forty-three,  and  melancholia,  thirty-seven).  Cranial  injuries  occur 
in  a  lai'ge  jiroportion  of  the  subjects  of  alcoholic  insanity  (18"9  per 
cent.),  but  this  element  comes  in  as  frequently  in  maniacal  as  in 
melancholic  states.  Of  the  circumstances  which  modify  the  type  of  the 
psychosis  age,  recurrence,  and  cranial  injury  may  be  excluded  from 
consideration ;  whilst  sex,  lieredity,  and  ancestral  intemperance  have 
some  influence  in  this  direction. 

Hallucinations  of  Special  Senses.— Illusions  and  hallucinations 
are  extremely  frequent  in  all  the  acute  forms,  as  well  as  in  a  large  pro- 
portion of  the  chronic  forms  of  alcoholic  insanity;  in  344  males  as  many 
as  131  (or  38  per  cent.)  presented  such  disturbed  sensorial  phenomena. 
The  visual  were  the  more  frequent,  and  visual  or  aural  were  separ- 
ately more  frequent  than  both  combined.  But  what  is  peculiarly 
characteristic  of  these  alcoholic  forms  of  alienation  are  the  illusoxy  anci 
hallucinatory  phenomena  of  the  nerves  of  g'eneral  sensation  and  of 
the  systemic  or  visceral  system  of  nerves,  giving  origin  to 
delusions  of  an  extraordinary  nature,  and  often  of  a  very  complicated 
system  of  intrigue.  Tingling,  prickling,  burning,  stinging  sensations 
over  different  areas  of  the  integument  are  frequently  complained  of; 
anaesthetic  patches  are  discovered  over  the  skin  of  the  arms  and  face, 
and  a  feeling  of  general  numbness  in  a  limb  may  ensue  ;  electric-like 
shocks  are  described  in  the  limbs,  and  head,  and  neck,  often  associated 
with  muscular  twitching,  or  facial  contortions;  and  these  subjective 
states,  induced  usually  by  centric  changes,  are  referred  to  an  objective 
origin,  giving  rise  to  the  most  varied  delusional  concepts,  such  as  those 
of  unseen,  mysterious  agencies  operating  upon  the  system — electi-icity, 
magnetism,  mesmerism,  Avitchcraft,  diabolical  machinery  are  in  turn 
invoked  to  account  for  these  mysterious  sensations.  In  like  manner, 
unusual  visceral  sensations  referred  to  the  heart,  lungs,  stomach, 
bowels,  itc,  become  the  basis  for  similar  delusional  beliefs  of  a  malign 
influence  within.  Belief  in  demoniacal  possession  is  not  uncom- 
mon, but   more  frequently   is  the    imagined    torture  supposed    to  be 


294  ALCOHOLIC    INSANITY. 

produced  l)y  individuals  known  to  tlie  patient,  who,  he  believes,  have 
the  power  of  operating  upon  him  from  a  distance,  or  have  obtained 
access  to  his  body,  and  restrict,  enslave,  and  govern  the  whole  life  of 
his  organism,  control  his  thoughts,  and  have  dominion  over  his  mind 
and  its  utterances. 

J.  J^.,  aged  thirty-one;  admitted  March,  1886.  Had  been  a  soldier,  and  for  the 
past  five  years  on  service  in  India;  he  was  invalided  by  "fever,"  confined  to  a 
military  hospital,  and  then  sent  home  to  England.  During  his  voyage  home,  a 
"galvanic  battery  began  to  ])lay  npon  him,"  and  he  heard  the  voices  of  his  late 
officers,  Capt.  P.,  Lieut.  C,  Drs.  W.  and  C,  talking  of  murders  and  other  crimes, 
although  they  were  not  present.  He  has  heard  these  voices  persistently  since  coming 
to  the  asylum ;  they  are  always  above  him,  and  he  points  up  to  a  distant  roof  of  the 
building  where  he  believes  they  are  located.  He  often  hears  the  whistling  of  gas 
over  his  head,  which,  he  says,  afi'ects  him  so  as  "  to  snip  a  word  in  two,"  just  as 
he  utters  it,  and  confounds  the  meaning  of  what  he  says — it  also  affects  his 
memory;  this  gas  is  produced  by  the  same  agencies  as  the  voices  which  he  hears. 
Flashes  of  lightning  show  him  all  the  events  of  his  life.  "  I  have  seen  my  whole 
life,  good  and  bad,  in  yon  back-yard  "  (referring  to  an  airing- court).  The  battery 
sends  electric  shocks  through  his  body,  causes  a  heavy  pressure  (not  a  paiu)  at  his 
epigastrium,  twitches  up  his  chest,  but  does  not  affect  arms  or  hands.  His  speech 
is  hesitating,  and  he  often,  in  explanation,  uses  the  statement  that,  "  Thetj  rule  my 
speech,  and  tell  me  what  I  have  to  say  at  times."  Has  noticed  foul  odours,  wliich 
he  knew  were  unnatural,  and  caused  by  "  the  electric  machine  ;  "  they  jjrevent  him 
from  sleeping.  These  malevolent  agents  are  treacherously  pursuing  him  wherever 
he  goes;  he  knows  not  why — he  cannot  rid  himself  of  them,  although  he  has 
"  oQered  them  his  life."  Frequent  twitchings  of  the  facial  muscles  on  the  left 
side  occur,  and  he  explains  them  as  due  to  the  electric  shocks,  which  draw  his 
breath  out  of  him  at  these  times ;  his  "  head  shakes,"  and  his  eyes  "  are  made  to 
twitch  thereby."  He  admits  having  been  of  very  intemperate  habits  since  the 
age  of  eighteen,  but  had  never  suffered  from  delirium  tremens;  both  his  father 
and  mother  were  excessive  drinkers.  He  himself  drank  raw  spirits  freely.  Had 
never  suffered  from  fit  or  stroke. 

Dynamometer  registers  for  right  hand  56  kilos.;  for  the  left  hand  54 — as  the 
average  of  four  trials. 

jEathesioivcter  gives  the  following  measurements  of  comparative  sensibility:  — 


1l'\])  of  forefinger, 

,,       thumb. 
Ball  of  thumb. 
Centre  of  palm, 
Wrist,  dorsal. 
Wrist,  volar. 
Forearm,  dorsal, 
Forearm,  volar. 

Sensibility  elsewhere  appears  good,  active,  without  delay ;  yet  he  complains  that 
his  legs  frequently  feel  "  dead,"  as  he  sits  at  table.  Both  knee-jerks  are  quite 
abolished;  yet  e(iuilibration  is  midisturbed,  he  balances  well  with  ej'es  closed; 
stands  on  tiptoe,  and  can  walk  "heel  and  toe"  along  a  straight  line;  plantar 


Right 

Side. 

Left 

Side. 

"05  of  an  inch. 

■05  of 

an  inch, 

•05 

•10 

■3 

•4 

•4 

•4 

•9 

rs 

1-7 

1-4 

2-8 

1-7 

1-9 

1-8 

DELUSIONS    OP   SUSPICION,    KTC.  295 

reflexes  are  good.  Has  never  had  pains  in  his  limbs,  but  flashing  pains  continually- 
pass  through  his  body  in  "all  directions."  No  eye-symptoms  are  apparent,  the 
pupils  are  equal,  the  reflexes  perfect ;  has  never  sufi'ered  from  diplopia  or 
strabismus. 

On  analysing  the  varied  delusions  in  male  alcoholics,  which  were 
well  expressed  in  208  out  of  344  individuals,  it  was  found  that  131 
entertained  ideas  of  persecution;  29  others,  religious  delusions  affecting 
their  moral  welfare ;  and  the  remaining  48,  optimistic  and  grandiose 
conceptions  ;  or,  as  tabulated,  thus  : — 


Nature  of  Delusions  in  Alcoholic  Males. 

C  ises. 


Percentage  of  whole 
(omitting  decimals 


Delusions  of  Persecution — 

(a)  By  poisoning, .  24  12 

{b)  By  magnetic  and  unseen,  mysterious,  agencies,  25  12 

(c)  By  various  other  means  beyond  the  above,       .  82  39 

Delusions  afi'ecting  the  moral  being,           ...  29           ,  14 

Delusions  of  grandeur  and  of  wealth,         ...  48  23 

208  Too 

Fpequency  of  Delusions  of  Suspicion.— Thus,  about  63  per 

cent,  of  such  false  notions  are  of  the  nature  of  delusions  of  suspicion, 
and  of  the  23  per  cent,  of  a  grandiose  and  optimistic  character,  it  was 
also  observed  that  such  notions  were  very  rarely  unmixed  with 
distrust  and  suspicion — the  exalted  position — the  large  possessions  or 
wealth  of  the  individual  being  cited  as  in  themselves  the  explanation 
of  the  malignity  of  his  imaginary  foes. 

A  summary  of  all  the  cases  of  delusions  of  mysterious  or  unseen 
agencies,  based  on  illusory  states  of  general  or  visceral  sensibility, 
vividly  suggests  the  terrible  mental  torture  which  these  alcoholic 
subjects  endure.  It  should  be  remembered  that  the  prevalence  of 
these  latter  forms  of  delusion,  based  on  illusions  of  the  nerves  of 
visceral  and  general  sensation,  is  much  greater  than  our  statistics 
would  lead  us  to  infer,  since  therein  are  comprised  only  definitely 
expressed  states  of  the  kind,  while  a  much  larger  section  exhibit 
suspicious  evidence  of  these. 

Optimistic  Delusions.  — These  states  of  optimism  closely  resemble 
those  presented  by  the  subject  of  general  paralysis,  in  the  inteiisity  of 
the  false  belief,  and  their  grossly  exaggerated  chax-acter,  but  they  differ 
in  almost  invariably  exhibiting  the  feeling  of  distPUSt  just  alluded  to, 
and  their  far  greater  fixity.  The  subject  is  restrained  in  the 
exercise  of  his  exalted  mission,  or  in  the  recovery  of  his  just  rights ; 
his  functions,  delegated  by  the  Almighty  or  by  a  great  earthly 
potentate,  ai-e   checked  by  the  malignity  of  his  former    friends    and 


29G 


ALCOHOLIC    INSANITY. 


relatives,  perhaps  by  his  own  wife  and  children,  to  all  of  whose  actions 
sinister  motives  are  attributed.  Aural  hallucinations  prompt  him  to 
action — a  voice  from  the  heavens  declares  to  him  his  mission — yet  his 
enemies  thwart  him,  endeavour  to  poison  him,  or  otherwise  ill-treat  him, 
and  this  leads  to  frequent  impulsive  violence.  Yet,  when  contrasted  with 
the  other  forms  of  delusion  of  pei'secution,  it  is  found  that  hallucinations 
which  are  found  in  one-half  of  these  cases  are  not  so  frequent  an 
accompaniment  of  the  exalted  mental  states,  occurring  in  but  one- 
fourth  of  the  series.  The  general  character  of  these  delusions  may  be 
gleaned  from  a  few  typical  cases — thus  one  of  our  patients  calls  him- 
self the  "Son  of  God,  and  the  Father  of  all  nations;"  another  declares  he 
holds  the  sun  and  moon  in  his  bauds,  and  regulates  the  movements  of 
the  planets ;  another  has  been  left  a  fortune  of  one  million  pounds 
sterling  by  Baron  Rothschild;  another  has  just  produced  a  great  patent 
"whereby  his  fortune  is  secured.  One  acute  case  (recovering  in  the  course 
of  four  months)  declares  that  he  drives  six  of  the  finest  horses  in  the 
world.  Noble  ancestry  is  boasted  of  by  some,  or  matrimonial  alliance 
claimed  with  members  of  royal  blood  ;  and  one  of  our  most  acute  cases 
always  spoke  of  his  wife  as  Queen  Elizabeth,  and  was  possessed  of 
fabulous  wealth ;  the  son  of  another  was  so  wealthy  that  he  was  about 
to  buy  up  Wakefield. 

Delusions  of  pePSeCUtion  comprise,  as  we  have  before  stated, 
nearly  G3  per  cent,  of  the  whole  series,  with  the  very  frequent 
association  of  hallucinations  of  the  special  and  general  senses.  A. 
very  large  proportion  of  such  entertain  ideas  of  poisoning — their 
food,  medicine,  or  tobacco  is  drugged ;  attempts  are  made  to  stupefy 
them  by  chloroform,  to  smother  them  when  asleep  in  bed,  and  to 
burn  them  alive;  ideas  of  murder  in  every  conceivable  way  are  rife; 
their  house  is  to  be  blown  up;  they  are  to  be  "cut  in  2)ieces  and 
boiled,"  or  divided  limb  from  limb,  and  "  their  bui'ied  children 
disentombed."  Policemen  dog  their  footsteps  ;  soldiers  lie  concealed 
in  their  houses;  voices  are  heard  next  door  intriguing  with  the 
wife  against  their  life ;  rats  and  vermin  surround  the  bed ;  the  wife's 
fidelity  is  frequently  called  in  question.  These  are  some  of  the  more 
prominent  instances  occurring  in  our  series  of  male  alcoholics,  of 
which  details  are  afforded  in  the  Table. 

Of  the  Clinical  forms  of  Alcoholic  Insanity.— We  shall  now 

proceed  to  a  study  of  the  varied  forms  of  alcoholic  insanity,  under 
their  respective  headings  of  acute  and  of  chronic  alcoholism  ;  premis- 
ing, that  by  the  former  we  indicate  a  purely  toxic  form  of  insanity  in 
which  the  mental  derangement  (often  very  acute  as  regards  intensity) 
is  of  rapid  course  and  short  duration — a  more  purely  functional 
derangement,  due  to  the  presence  of  the  poison  in  the  system ;  and 


MANIA    A    POTU.  297 

tliufc  by  the  latter  we  refer  to  the  more  remote  effects  of  tlio  pr)i.s()n  in 
altering  structure,  through  modifying  the  nutrititni  of  thi;  censl^ro- 
spinal  system — an  insanity  based  upon  organic  disease  of  the  brain  and 
spinal  cord.  The  statistics  already  dealt  with  when  considering 
alcoholic  insanities  generally,  have  presented  us  with  some  50  per 
cent,  of  cases  running  a  rapid  course  towards  complete  recovery ;  but 
in  which  there  are  also  some  40  per  cent,  of  others  whose  recoveries 
were  very  partial,  or  death  resulted,  or  the  patient  remained  an 
addition  to  the  chronic  insane  community.  It  is  upon  such  categories 
we  shall  now  draw  for  illustrations  of  the  various  phases  presented  by 
the  mental  perversions  induced  by  prolonged  alcoholic  excess. 

Acute  Alcoholic  Insanity. — Under  this  term  we  com])rise  mania 
a  ■potu,  or  the  acute  alcoholic  delirium  of  Magnan,  and  delirium  tremens, 
or  "  febrile  "  delirium  tremens  of  Magnan. 

Mania  a  fotu  {acute  alcoholic  deliriu7n ;  deliruni  ebriosum). — Our 
patient  usually  comes  befoi-e  us  in  a  state  of  acute  maniacal  excitement, 
and  with  some  such  history  as  the  following  : — He  has  been  for  a  long 
period  addicted  to  intemperate  habits — perhaps,  not  so  much  contin- 
uous, heavy  drinking,  as  repeated  excesses,  often  with  prolonged 
intervals  of  comparative  sobriety  between  the  bouts.  There  is  jn'o- 
bably  a  clue  to  one  or  more  attacks  of  delirium  tremens,  from  which 
on  recovery  he  has  shortly  relapsed  into  his  former  excesses  leading 
to  an  acutely-delirious  outburst. 

It  is  by  no  means  unusual  to  be  told  that,  for  several  weeks  prior  to 
the  seizure,  there  had  been  entire  abstinence  from  alcoholic  indul- 
gence ;  but  that  the  health  had  been  notably  affected,  with  gastric 
disturbance  and  general  malaise ;  nervous  symptoms  had  been  pro- 
minent, and  mental  instability,  moroseness,  irritability,  insomnia, 
hideous  dreams,  and  nervous  startings  had  been  witnessed ;  and  that, 
consequently,  on  the  occurrence  of  some  moral  agency,  shock,  grief, 
disappointment,  &c.,  an  exciting  cause  is  afforded  sufficiently  potent  to 
develop  the  attack  of  mania.  Our  enquiries  probably  elicit  the  fact 
of  hereditary  predisposition  to  insanity — possibly  of  ancestral  intem- 
perance ;  but  especially  are  we  likely  to  discover  that  the  subjects 
have  been  regarded  as  congenitally  defective  in  self-control,  as  wanting 
in  moral  tone,  and  as  the  victims  of  a  stunted  development,  in  which 
instinctive  desires  and  impulsive  responses  predominate  over  higher 
intellectual  promptings.  The  excitement  is  often  one  of  great  intensity ; 
but,  in  this  respect,  we  witness  various  depths  of  reduction,  yet  all 
forms  are  invai'iably  accompanied  by  characteristic  illusions  and  hallu- 
cinations ;  in  fact,  the  m.ost  notable  feature  of  the  delirium  is  the 
predominance  presented  by  such  sensorial  disturbance.  In  typical 
deliritim  tremens  motor  symptoms  are  as  prominent  a  feature  as  the 


298  ALCOHOLIC    INSANITY. 

sensorial ;  whilst  in  the  more  clironic  forms  uf  alcoliolism,  as  we  shall 
see  later  on,  we  get  both  features  less  emphasised,  less  acute,  and, 
together  with  intellectual  enfeeblement,  assuming  a  permanence  want- 
ing to  the  acute  forms. 

The  special  sense  illusions  and  hallucinations  are  ever  of  a  most 
distressing  natui-e,  usually  very  vivid,  and  exhibit  the  usual  mobile 
state  of  such  sensorial  anomalies  seen  in  acute  mania.  This  fleeting 
character  is  in  itself  of  favourable  augury  when  contrasted  with  the 
more  persistent  fixity,  or  monotonous  repetition,  seen  in  other  states 
of  mental  disease,  and  indicative  of  an  approaching  or  of  an  established 
chi'onicity.  The  variable,  fleeting  nature  of  the  sense-disturbances  in 
alcoholics  has  been  long  recognised  (Lasegue,  Alagnan).  The  forms 
thus  coujured-up  by  the  disordered  sensorium  bear  a  striking  resem- 
blance to  the  other  form  of  acute  alcoholism,  delirium  tremens,  as  also 
to  the  phenomena  described  as  induced  by  certain  drugs,  notably 
hyoscyamine  [Robert  Lawson).  As  under  the  influence  of  hyoscyamine, 
pleasurable  or  painful  visions  troop  before  tlie  mind's  eye  incessantly ; 
yet  the  general  mood  in  acute  alcoholism  is  always  painful,  and  the 
visions,  however  fascinating  in  character,  beget  distrust  and  suspicion. 
Much  more  frequently  are  these  false  impressions  of  a  most  painful, 
terrif^dng  nature ;  and  hideous,  loathsome  forms  surround  the  victim. 
Snakes,  tigers,  furious  dogs  are  seen  or  heard,  and  the  attendant  is 
transformed  by  tlie  diseased  mind  into  a  fiend  or  other  dreaded  form. 

If  we  now  test  our  patients  carefully,  we  discover  in  many  a  very 
decided  degree  of  amhhjopia — vision  is  clouded,  and  the  visual  activity 
diminished;  and,  with  the  amblyopia,  there  is  also  occasionally  con- 
joined a  difficult  perception  of  colours  [dyschromxitopsia).  It  has  been 
shown  by  M.  Galezowski  that  the  cliromatic  aniesthesia  thus  produced 
pertains  chiefly  to  the  composite  colours,  and  especially  yellowish-  and 
bluish-greens.  Impaired  or  perverted  sensibility  may  also  be  recog- 
nised in  other  sensory  expansions,  as  the  olfactory  and  gustatory  ; 
the  palate  is  in  all  cases  more  or  less  art"ected,  and  tlie  antesthetic  con- 
dition of  tlie  upper  lip  is  an  early  symptom  familiar  to  all  who  indulge 
too  freely  in  alcoholic  drinks.  Similar  anaesthesias,  byperaesthesias, 
and  perverted  states  of  general  cutaneous  sensibility  have  likewise 
been  apjjealed  to  as  explanatory  of  the  many  forms  of  illusion  pertain- 
ing to  the  surface  of  the  body  from  which  alcoholics  sufter.  That 
these  sensorial  expansions  do  become  aff"ected  seriously  in  acute 
alcoholism  is  undoubted  ;  but  such  symptoms  are  of  transient  duration, 
and  are  far  more  frequent  in  chronic  alcoholics  ;  they  but  indicate  the 
taking  oft'  "  of  the  fine  edge,"  which  all  mental  faculties  alike  suflfer. 
from  as  the  result  of  alcoholic  reductions. 

Relapses. — Alcoholic  excess,   long    ere    structural   change   can   be 


SENSOHIAL    TIIOUBLES    IN    ALCOHOLISM.  299 

predicted  in  tlie  nervous  centres,  is  answerable  for  something  more 
than  the  mere  transient  functional  disturbance  described  ;  it  engenders 
a  nutritive  perversion,  which  is  more  marked  after  each  attack  of 
acute  alcoholism,  and  which  is  expressed  in  a  notable  tendency  to 
recurrence.  This  i-elapsing  character  is  especially  seen  during  the 
progress  of  the  alcoholic  subject  under  treatment ;  repeated  outbursts 
of  excitement  occur,  after  intervals  of  comparative  calm  and  often 
apparent  convalescence,  ere  the  case  may  be  considered  fit  for  dis- 
charge from  asylum-supervision.  Thus,  in  the  case  of  /.  J.,  four 
distinct  relapses  occur  during  one  year  of  his  residence  at  the  asylum, 
and  although  the  remissions  were  not  so  complete  as  in  many  cases, 
yet  it  was  sufficiently  apparent  in  his  case  that  each  relapse  was 
characterised  by  symptoms  exactly  reproducing  his  previous  state  ; 
and  that  the  immediate  exciting  cause  was  some  trifling  moral 
agency,  such  as  a  dispute  with  a  patient,  or  some  trivial  disappoint- 
ment. It  is  all-important  for  tts  to  recognise  the  fact,  that  the 
presence  of  alcohol  in  the  blood  or  tissues  is  not  necessary  to  the 
continuance  of  the  characteristic  delusions  of  persecution,  to  which 
these  individuals  are  subject ;  it  is  in  the  nutritive  change  engendered 
in  the  nerve-cells  of  the  cortex  through  the  agency  of  alcohol,  that 
a  more  permanent  instability  of  the  discharging  centres  becomes 
established,  and  the  mental  anomalies  assume  gradually  a  more  stereo- 
typed aspect.  Whatever  be  the  centres  of  the  brain  which  ai-e  more 
prone  to  disturbance  through  the  agency  of  alcohol — when  once  their 
nutritive  equilibrium  is  upset  seriously  by  this  agency — these  centres 
are  prone  to  stiffer  first  in  any  relapse,  whatever  be  the  exciting 
cause. 

The  case  of  W.  W.   will  illustrate  this  point  :  — 


W.  W.,  aged  forty,  coal-miner;  admitted  Feburary,  1885.  Mother  had  been  an 
inmate  of  this  asylum,  and  was  said  to  have  died  in  Pontefract  Hospital  from 
softening  of  the  brain.  The  patient  was  a  heavy  drinker  until  ten  months  previous 
to  his  entry  into  this  asylum ;  an  attack  of  mental  disorder,  the  nature  of  which  is 
unknown,  but  which  was  treated  at  home,  served,  however,  to  check  his  habits  of 
intemperance.  From  that  time  he  worked  steadily,  at  such  scanty  employment  as 
he  could  procure,  till  within  a  week  of  his  admission  here,  when  he  was  seized 
suddenly  with  .symptoms  of  excitement  and  ravings  on  religious  topics ;  this 
speedy  onset  was  attributed,  by  his  friends,  to  his  attendance  at  the  Salvation 
Army  meetings  and  consequent  excitement.  On  his  reception  into  the  asylum,  he 
was  .suffering  acute  mental  depression,  and  was  too  agonised  to  offer  any  information 
regarding  his  subjective  state ;  but,  according  to  the  certificate,  he  had  avowed  the 
delusions  that  "  tliere  were  devils  inside  him,  and  that  a  man  h.ad  come  outside  his 
house  to  attack  him,"  and  he  had  taken  up  a  poker  in  order  to  kill  him.  In  a  few 
days,  having  quieted  down,  he  affirmed  that  he  heard  people  coming  down  on  the 
top  of  his  head,  and  although  he  could  not  remember  what  they  said,  comprehended 


300  ALCOHOLIC    INSANITY. 

it  at  the  time;  was  fearful  of  sleeping  at  night.  IJajiid  convalescence  supervened, 
delusions  and  hallucinations  disap[ieared,  and  the  patient  was  discharged  six  weeks 
after  entry. 

Here  then,  we  find,  after  nine  months'  abstinence,  the  recurrence 
of  acute  melancholia  apparently  attrilmtable  to  the  morbid  excite- 
ment of  certain  religious  services.  In  every  feature  the  attack 
reproduced  what  was  previously  engendered  as  the  direct  result  of 
heavy  alcoholic  indulgence ;  and  it  is  well  to  be  familiar  with  the 
fact,  that  the  symptoms  of  acute  alcoholism  may  thus  be  over  and 
over  again  reproduced,  without  fresh  excesses,  when  the  cerebral 
nutrition  has  been  impaired  as  above  described.  It  is  noticeable  how, 
in  the  case  just  described,  the  characteristic  hallucinations  and 
delusions  were  also  freely  interspersed  with  religious  delusions,  and 
how  his  ramblings  brought  prominently  into  relief  the  subject  with 
which  he  had  been  chiefly  occupied  at  the  onset  of  his  attack.  As 
Magnan  and  othei's  have  noted  in  other  cases,  here  also  the  hallucina- 
tions gradually  lose  their  definiteness,  a  confused  voice  replacing  tiie 
alarming  cry  of  "  poison  !";  then  the  voices  are  in  their  turn  replaced 
by  an  occasional  humming  sound  in  the  ears,  which  ultimately  fades 
away  upon  his  recovery.  It  is  impossible  not  to  be  impressed,  when 
attentively  studying  such  gradual  recoveries,  with  the  apparent 
obnubilation  of  the  illusory  states  by  the  strenr/theninr/  itn^ii-essions  of 
ohjeciive  existences,  forcibly  reminding  one  of  what  occurs  occasionally, 
even  in  perfectly  healthy  states,  when  awaking  from  sleep ;  illusory 
states  are  then  not  infrequent  ere  more  vivid  preseutative  feelings 
force  themselves  into  being.  In  a  case  of  mania  a  potu*  (IF.  R.) 
special  interest  attached  itself  to  the  visual  illusions  to  which 
the  patient  was  subject,  especially  at  the  moment  of  waking.  It 
was,  as  it  were,  a  projection  of  a  dream  into  his  waking  hours,  frag- 
ments of  the  illusory  dream  persisting  and  refusing  for  some  little 
time  to  be  dispersed  ujoon  the  reinstatement  of  wakeful  consciousness. 
This  state  is  not  unfamiliar  in  normal  health  ;  and  a  case  is  known  to 
the  writer,  where  for  some  time  after  aj)parently  complete  wakefulness, 
the  subject  saw  distinctly  what  he  conceived  to  be  his  own  corpse 
lying  in  a  collin  beside  his  bed,  and  which  for  some  time  he  failed 
to  resolve  into  its  real  elements  of  a  bundle  of  clothing.  We  reason- 
ably conclude  that  such  resolution  is  affected  by  the  freer  circulation 
in  higher  cortical  realms ;  and  that  zones  ])reviously  ansemic  become, 
on  complete  wakefulness,  once  more  the  site  of  functional  activity. 
There  is  a  strong  presumption  that  a  parallel  condition  exists  in 
acute  alcoholism,  and  that  a  projection  of  hideous  dreau)s  and    frag- 

*  See  on  this  point,  J/«j7«a)i— Transl.  by  Dr.  Greenfield,  p.  50. 


IMI'ULSIVK    VIOLENCK.  301 

montary  detaclied  illusory  states  arc  thus  interininglod  with  tlio 
realities  of  waking  hours;  the  wliolc  history  of  the  case  during  its 
acvite  stage  is  that  of  a  waking  dream.  The  re-energising  of 
higher  cortical  planes  which  occurs  during  waking  may  require  a 
certain  well-defined  interval,  and  in  lieu  of  dispersing  any  exis- 
tent morbid  symptoms  will,  in  certain  conditions,  call  them  into  full 
activity  as  in  the  movements  of  paralysis  agitans.  Thus  in  a  case  of 
Charcot's  hemii)legic  type  of  j^cirabjsis  agitans,  the  writer  well  I'ecalls 
the  statement  of  the  patient  that  the  hand  which  was  the  site  of 
continuous  fumbling  movements  during  complete  consciousness,  and 
especially  during  voluntary  action,  remained  often  quiescent  for  some 
time  after  waking — a  very  appreciable  interval  existing  before  the 
afi'ected  centres  were  sufficiently  energised  to  permit  of  their  inter- 
mittent discharge. 

In  the  case   of   W.   1>.   it  is  also  to  be  noted  that  both  he  and  his 
grandmother,    "  could   foresee   events,"   by  which  we  may  infer  that 
both  were  subject  to  these  peculiar  waking  dreams,  and  were  apt  at 
such  moments  to  confuse  illusory  appearance  with  actual    existence, 
and  visions  arose  before  them  in  their  waking  hours.     It  is  by    no 
means  unusual  amongst  the  insane  to  discover  a  power  of  calling  into 
existence  such   illusory   appearances ;  and   we  are  frequently  told  by 
them  that  they  have  the  power  of  conjuring  up  almost  any  form  they 
choose ;  nor  is  this  to  be  wondered  at,  if  the  analogy  of  dreaming  be 
considered ;  for  we  opine  that  the  morbid  imagery  is  always  ready  (in 
certain  cases)  to  spring  into  life,  but  are  suppressed  by  the  attentive 
direction  of  the  mind  to  presentative  states ;  if,  on  the  other  hand, 
such    contrasting    states    are    voluntarily    suppressed,     the     morbid 
imagination  may   have  fidl  play.      At  all  times  liable  to  dangerous 
impulsiveness,  the  acute  alcoholic  is  a  fortiori  more  prone  to  exhibit 
such  impulses  at  night ;  and  especially,  when  roused  from  slumber,  at 
the  moment  of  loaldng,  from  the  occurrence  then  of  vivid,  illusory,  and 
hallucinatory    states.       A   colleague    of    the    writer's   thus    narrowly 
escaped  with  his  life  a  violent  attack  on  the  part  of  a  patient,  who  had 
concealed  beneath  his  bedding  an  improvised  weapon,  with  which  to 
attack  the  medical  officer  at  the  night-visit  to  his  bedside ;  and  who 
confessed  subsequently  that  each  night  he  had  imagined  his  visitant  to 
be  under  the  form  of  Satan,  and  planned  this  means  of  attack  upon 
him.     Such  impulsiveness  very  frequently  betrays  itself  in  suicidal 
attempts ;  and   we    find   by    our    statistics  as    many   as  40  per   cent, 
regarded  as  decidedly  suicidal.     According  to  Bouclereau  and  Magnan, 
from  7  to  15  per  cent,  of  alcoholic  cases  attempt  suicide.     The  latter 
writer   is  especially   guarded   in   distinguishing   genuine  suicidal  and 
homicidal  attempts  from  mere  accidents,  which  are,  of  course,  peculiarly 


302  ALCOHOLIC   INSANITY. 

prone  to  occur  in  the  terror  infused  by  the  delusional  states  of  acute 
alcoholics.  Such  suicidal  impulses  may  be  associated  with  desperate 
conduct,  not  truly  homicidal  nor  suicidal  but  having  as  its  object  the 
relief  of  the  existing  tortui-e. 

G.  S.,  aged  forty-seven,  married,  a  woollen  spinner  by  occupation.  For  two 
months  prior  to  admission  lie  had  been  depressed,  sleepless,  and  had  taken  but 
little  food.  A  fortnight  before  he  would  not  leave  his  house,  was  silent,  sullen, 
and  obstinate,  betraying  much  terror  because  he  was  "to  be  taken  away  and 
deserved  hanging. "  Wife  stated  that  for  years  he  had  been  an  excessively  sottish 
drinker,  but  less  intemperate  for  the  past  six  months.  Brother  was  insane. 
Patient  was  a  fairly  nourished,  muscular  individual,  well  built,  with  a  hea\'y, 
stupid  expression,  sluggish  in  all  his  movements,  his  whole  bearing  indicative  of 
great  apathy.  He  was  very  illiterate ;  was  reticent,  wilful,  and  refuseil  food 
upon  admission.  There  was  no  oculo-motor  paralysis ;  tongue  was  protruded 
straight  and  steadily — it  was  covered  with  foul  epithelia ;  heart's  action  feeble, 
no  murmur.  Abdominal  viscera  apparently  free  from  all  but  slight  functional 
derangement. 

During  his  first  week's  residence,  when  sleeping  under  observation,  he  suddenly 
sprang  out  of  bed,  threw  himself  upon  a  patient  next  to  him  without  any  pro- 
vocation, and  nearly  strangled  hini ;  he  was  removed  to  a  single-room  where  he 
was  discovered  mutilating  himself,  having  succeeded  in  inflicting  a  deep  mcision 
with  his  finger  nails  around  the  penis. 

Up  to  this  period,  he  had  been  taking  morphia ;  hyoscyamine  (J  gi-.  Merck's 
Extract)  was  now  ordered.  A  month  after  admission  it  is  noted — "  Much  quieter, 
but  still  has  a  hang- dog  look,  as  if  m\ich  afraid  of  something  or  someVjody  ;"  and, 
a  few  days  later,  he  became  greatly  excited  and  suspicious,  attacking  his  night- 
attendants  and  fellow- patients.     Chloral  (grs.  xxx)  ordered  ni;;^ht  and  morning. 

Musciilar  enfeeblement,  especially  of  the  loioer  limhs,  was  now  noted  ;  in  his 
wild  excitement  he  frequently  fell  and  bruised  himself  badly,  so  that  he  had  to 
be  confined  to  his  bed  in  a  padded  room.  Six  weeks  after  admission,  the  excite- 
ment had  passed  away  ;  patient  was  left  extremely  depressed  in  spirits  and  pro- 
foundly demented  ;  was  very  restless,  and  utterly  negligent  in  hal)its. 

He  had  at  this  time  the  aspect  of  an  advanced  general  paralytic,  but  with  no 
labial,  lingual,  or  ocular  paralysis.  Some  paralysis  of  the  muscles  of  deglutition 
subsequently  supervened,  necessitating  very  cautious  feeding.  He  remained  help- 
less, bedridden,  and  extremely  demented,  dying  somewhat  siuldenly  six  months 
after  admission. 

Secfio  cadav.  Skull  cap  bulging  in  left  parietal  region,  bones  generally  thick, 
very  dense  and  almost  devoid  of  diploii ;  sinuses  contained  dark  clotted  blood ;  there 
was  no  adhesion  of  dura" mater.  The  brain  exteraally  very  pale,  was  of  average 
consistence,  and  the  membranes  were  slightly  clouded  in  frontal  and  parietal 
regions,  where  the  convolutions  were  equally  and  slightly  wasted  in  both  hemi- 
spheres ;  no  external  tract  of  softening.  The  pia  stripped  with  great  freedom 
from  all  parts,  and  the  soft  membranes  were  generally  thickened  and  buoyed  up 
as  in  senile  atrophy.     There  was  no  atheroma  of  the  basal  vessels. 

Whole  brain  weighed  .  1432  grms.  Left  frontal  lobe  weighed  2.35  grms. 

Eight  hemisphere  ,,     .  630     ,,  Cerebellum  ,,        150     ,, 

Left  „  ,,     .  624    „  Pons  „  17     „ 

Right  frontal  lobe  ,,     .  2S6    ,,  Medulla  ,,  6     ,, 


CHRONIC   ALCOHOLISM.  303 

The  gvey  matter  of  cortex  was  normal  to  the  naked  eye  ;  the  white  suVjstance 
was  somewhat  softened,  but  presented  no  coarse  vessels  ;  there  was  no  recent  or 
old  focus  of  softening  or  hivmorrhage.  Heart  weighed  272  grms.,  the  organ  was 
normal. 

Right  lung,  994  grms. ;  adherent  at  apex  by  old  fibrous  tissue,  by  which  also 
the  lobes  were  united  firmly  together ;  generally  congested  and  presenting  at 
extreme  base  a  small  cheesy  nodule. 

Left  lung,  574  grms. ;  apparently  normal  throughout. 

Liver,  1,708  grms.;  capsule  much  thickened  ;  substance  congested. 

Spleen,  108  grms.;  normal. 

Eight  kidney,  141  grms.;  left  kidney,  165  grms.  Both  organs  were  considerably 
lobulated  ;  capsules  firmly  adherent,  leaving  on  removal  a  distinctly  granular 
surface ;  cortex  was  much  wasted,  structure  firm,  fibrous,  granular ;  pyramids 
obviously  diseased  ;  right  organ  in  most  advanced  state  of  degeneration. 

The  case  of  J.  B.  (p.  216),  is  a  typical  one  of  mania  a  potu  passing- 
into  chronic  alcoholism  in  a  subject  predisposed  to  insanity,  and  inherit- 
ing the  resvilts  of  paternal  intemperance.  Prior  to  his  visit  to  America, 
his  seizures  were  of  the  nature  of  acute  alcoholism ;  bvit,  upon  his  return 
to  England,  the  fixed  delusion  of  the  machinery  in  his  chest  augured 
the  transition  towards  chronic  alcoholism.  In  the  latter  stage  we 
observe  the  tendency  to  allude  to  his  sufferings  as  terrible,  and  to 
speak  in  the  most  exaggerated,  terms  of  the  tortures  to  which  he  is 
subject.  This  is  a  feature  highly  characteristic  of  chronic  alcoholism ; 
such  exaggerated  statements  are  not  wilful  misrepresentations,  for 
the  subject  fully  conceives  the  terrors  he  depicts.  The  suffering  is 
evidently  not  extreme  physical  suffering,  but  a  distortion  of  disordered 
sensations,  so  that  slight  pains  and  discomfort,  from  a  loss  of  balance 
in  comparison,  are  apt  to  be  magnified  into  voluminous  distressing 
feelings.  Such  subjects  usually  have  hearty  appetites,  gain  flesh, 
and  enjoy  themselves  freely,  when  their  attention  is  distracted  from 
their  subjective  states ;  but,  immediately  they  are  spoken  to  concern- 
ing their  delusions,  the  hypochondriacal  self-engrossment  is  assumed, 
and  they  begin  to  lament  their  pitiable  condition. 

Cases  of  alcoholic  delirium  have  been  divided  by  Magnan  into 
three  groups,  viz.  : — 

1.  Those  affected  with  alcoholic  delirium,  with  easy,  complete,  and 
rapid  convalescence. 

2.  Those  affected  with  alcoholic  delirium,  of  slow  convalescence, 
with  ready  relapse. 

3.  Those  specially  predisposed,  who  have  frequent  relapses,  and  a 
convalescence  interrupted  by  delirious  ideas,  and  in  which  the 
intellectual  disturbance  is  from  the  outset  much  more  notable  than 
the  motorial. 

Chronic   Alcoholism. — The   establishment  of  persistent  nervous 


304  ALCOHOLIC    INSANITY. 

symptoms  as  the  result  of  too  fi-et;  an  indulgence  in  intoxicating  liquors, 
has  been  for  centiu-ies  recognised  by  the  ))rofession.  Even  in  classic 
times,  we  find  occasional  allusion  to  such  states  (Soieca).  Nor,  indeed, 
could  we  conceive  this  to  be  otherwise,  if  we  take  into  account  the 
excessive  vicious  indulgence  of  the  luxurious  class  in  the  later  Roman 
Empire.  Nearer  our  times,  Lettsom  has  clearly  demonstrated  the 
sensory  and  motor  troubles  induced  by  long-continued  alcoholic  indulg- 
ence ;  but,  it  was  not  until  quite  recent  days  (1852),  that  a  group  of 
symptoms  was  formulated  as  constituting  a  distinct  morbid  entity  under 
the  name  of  chronic  alcoholism,  and  to  Dr.  Magnus  Huss,  in  parti- 
cular, is  due  the  credit  of  clearly  enunciating  the  relationship  of 
this  important  disease,  which  in  his  day  was  making  such  sad  havoc 
among  his  countrymen.  Northern  nations  have  always  been  most 
susceptible  to  the  alluring  temptation  of  alcohol ;  the  Russian, 
>Scandinavian,  and  Scotch,  being  notoriously  addicted  to  the  vice. 
In  Sweden,  the  consumption  of  large  potations  of  raw  spirit  by  all 
classes  of  the  population  (and  especially  of  a  most  impure  and 
pernicious  spirit,  distilled  from  diseased  potatoes,  which  formed  the 
staple  commercial  article),  proceeded  to  such  an  extent  as  to  demand 
State  interference,  in  which  the  reigning  family  and  the  medical 
profession  took  a  prominent  part,  doing  much  to  point  out  the 
pernicious  social  effect  of  the  habit,  and  check  its  further  advance. 
The  raw  brandy  thus  consumed  in  Sweden  was  not  only  notoriously 
impure  and  noxious,  but  correspondingly  cheap,  and  the  most 
deleteiious  effects  were  widely  apparent.  It  is,  therefore,  not 
surprising  that  the  most  valuable  treatise  upon  chronic  alcoholism 
should  have  emanated  from  our  Scandinavian  neighbours,  and  that 
in  the  classic  work  of  Magnus  Huss*  we  find  detailed  in  no  uncertain 
terms  the  ominous  group  of  symptoms  constituting  a  disease,  whose 
differential  diagnosis  before  his  day  had  been,  to  say  the  least,  most 
obscure  and  ill-defined. 

Van-der-Kolk  +  dealt  with  alcoholism  as  he  met  with  it  in  Holland  ; 
and  later  (187G),  Magnan  I  has  done  for  France,  in  his  elaborate 
treatise  on  alcoholism,  what  Huss  did  for  Sweden ;  and  in  our  own 
country,  Drs.   Carpenter,  §  Marcet,  ||  Anstie,  U  Wilks,  **  and  Parker, 

*  AlcohoUsmiis  Chronicus.     Dr.  M.  Huss,  Stockholm,  1S49  51. 

t  Jvflnence  of  Stroiuj  Drinks  on  the  Human  Budij,  by  J.  L.  C.  Schnieder 
Van-der-Kolk.     Utrecht,  1S53. 

X  Alcoholi'^m.     Dr.  V.  Magnan.     Translated  by  Dr.  Greenfield,  1S70. 

§  Use  and  Abuse  of  Alcoholic  Liquors  in  Health  and  Disease.  W.  B.  Carpenter, 
1S50. 

II  Chronic  Alcoholic  Intoxication.     Dr.  Marcet,  1S62. 

^  Stimulants  and  Xarcotics.     Dr.  Anstie.     Macinillan,  1864. 
**  Alcoholic  Paralysis,     Dr.  Wilks.     Lancet,  1S72. 


CHRONIC   ALCOHOLISM.  305 

have,  amongst  many  otliers,  contributed  largely  to  the  physiological, 
clinical,  and  pathological  aspects  of  alcoholic  intoxication,  and  its 
ulterior  effects  upon  the  nervous  economy.  Nor  must  we  omit  to 
mention  the  highly  suggestive  experiments  of  Dr.  Ogston  and  of 
Dr.  Percy,  *  which  gave  so  great  a  stimulus  to  further  research  into 
the  physiological  action  of  alcohol,  and  from  which  have  directly 
emanated  the  more  enlightened  views  now  held  respecting  the 
physiological  operation  of  this  agent,  its  true  dietetic  and  therapeutic 
value,  and  its  operation  as  an  incitor  to  morbid  change. 

It  is  unnecessary  here  to  do  more  than  very  briefly  allude  to  the 
injurious  efiects  of  alcohol  on  systems  other  than  the  nervous.  Dr. 
Carpenter's  "Prize  Essay"  did  much  to  popularise  true  ideas  on  the 
subject,  portraying  in  vivid  colours,  as  it  did,  the  injurious  effects  of 
drunkenness  upon  all  the  tissues  of  the  organism.  The  chronic 
gastric  catarrh ;  the  hsemorrhagic  mucous  membrane ;  the  inter- 
stitial changes  in  the  liver  and  kidney  ;  f  the  atheromatous  condition 
of  the  blood-vessels  ;  the  fatty  changes  in  various  organs,  and  notably 
in  the  heart ;  the  functional  disturbances  leading  to  albuminuria, 
ascites,  anasarca,  gout,  rheumatism,  and  the  long  list  of  nervous 
ailments ;  all  these  are  familiar  to  any  one  who  has  paid  attention 
to  the  subject.  It  is  well,  however,  to  recall  to  mind  certain  estab- 
lished physiological  facts  as  our  groundwork  for  further  observation. 

(1.)  Alcohol  may  be  absorbed  through  the  serous,  mucous,  or  respir- 
atory surfaces  ;  the  last  fact  was  demonstrated  by  Orfila,  who  produced 
drunkenness  by  the  inhalation  of  the  vapour. 

(2.)  It  is  absorbed  unchanged ;  and  may  leave  the  system  in  an 
unchanged  form,  since  it  has  been  detected  by  appropriate  tests  in  all 
the  fluids  and  in  many  of  the  tissues.  Thus  Dr.  Percy,  relying  on  its 
odour  and  inflammability,  found  it  in  the  bile,  urine,  blood,  the  liver, 
and  the  brain ;  whilst  Rudolf  Masing,  1854,  |  and  subsequently, 
MM.  Lallemand,  Perier,  and  Duroy  detected  it  by  the  chrome  test  S 
in  exhalations  from  the  skin  and  in  the  urine. 

(3.)  As  early  demonstrated  by  Dr.  Percy's  experiment,  it  is  found  in 
proportionately  largest  quantity  in  the  brain ;  evidencing,  according 
to  that  authority  and  Dr.  Carpenter,  a  peculiar  "  elective  affinity  "  of 
nervous  tissue  for  alcohol. 

(4.)  Changes  of  a  profound  significance  are  induced   in   the  blood 

*  An  Experimental  Enquiry  concerning  the  presence  of  Alcohol  in  the  Ventricles  of 
the  Brain.     1839. 

t  The  frequency  of  its  action  on  the  kidney  has  been  denied  by  Dr.  Dickinson 
and  Dr.  Anstie.     Medical  Times  and  Gazette.     November,  1872. 

X  Da  rdle  de  V Alcohol  et  des  Anesthetiques  dans  I'Orr/miisme.     Paris,  1860. 

§  Bichromate  of  potash,  1  grain  ;  sulphuric  acid,  10  grains. 

20 


306  ALCOHOLIC   INSANITY. 

itself  at  an  early  period,  laying  the  foundation  for  the  various  tissue- 
changes  which  ensue,  and  which  directly  aff'ect  the  well-being  of  the 
nervous  centres  by  the  immediate  functional  disturbances  which  are 
induced  by  the  agency  of  the  nutritive  pabulum  of  the  blood.  Such 
changes  are  the  devitalisation  of  the  red  corpuscles  leading  to  impaired 
reration ;  to  the  accumulation  of  hydro-carbon  in  the  blood-current, 
fatty  specks  in  the  red  globules,  whilst  it  causes  these  globules  to  be 
very  slowly  reddened  on  exposure  to  air. 

(5.)  Paralysis  of  the  sympathetic  system,  leading  also  to  impaired 
nutrition  and  an  extravagant  expenditure  of  animal  heat. 

The  effect  of  alcohol  in  stunting  the  growth  of  the  body  is  a  well- 
known  fact ;  animals  may  thus  be  affected  when  fed  from  an  early  age 
upon  alcohol.  At  the  West  Riding  Asylum  a  dog,  to  which  alcohol 
had  been  administered  for  a  lengthened  period,  not  only  succumbed  to 
all  the  symptoms  described  in  alcoholism  in  animals  by  Magnan 
(hallucination,  terror,  savage  temper,  motor  tremblings,  and  paralysis); 
but  the  nutrition  of  the  skeleton  also  became  affected,  so  that  a  notable 
degree  of  mollities  and  attendant  deformity  ensued.  Upon  death, 
extensive  fatty  degeneration  of  the  nerve-cells  and  arteries  of  the 
cerebrum  was  observed.  The  dwarfed  stature  of  our  mining  com- 
munity (amongst  whom  excessive  indulgence  in  drink  is  only  too 
frequent)  is  largely  due  to  this  cause,  associated  with  the  abnormal 
conditions  of  their  life  and  strong  hereditary  proclivities. 

Period  of  Evolution  of  Nervous  Symptoms.— Important  as 

it  is  that  we  should,  for  the  sake  of  statistical  accuracy,  arrive  at 
definite  views  as  to  the  period  during  which  alcoholic  indulgence  may 
be  prolonged  (ere  permanent  nervous  symptoms  are  indicated),  it  is 
apparent,  at  first-sight,  that  the  question  is  one  of  extreme  difficulty ; 
and,  with  our  existing  data,  cannot  be  answered  with  even  an  approach 
to  accuracy.  Much  dvspends  upon  the  hind  of  drink  indulged  in,  the 
specific  effects  of  raw  spirit,  wines,  malt  liquors,  absinthe,  and  other 
drinks  being  too  well  recognised  to  be  dealt  with  here ;  much  dei)ends 
also  upon  the  quantity  taken ;  the  eliminating  powers  of  the  system  ; 
sex ;  certain  diatheses  (as  the  aguish)  where  the  individual  can  take 
large  quantities  often,  are  all  important  points. 

As  regards  neurotic  inheritance,  it  is  certain  that,  from  this  class  of 
the  community,  drink  reaps  its  greatest  quota  of  the  more  persisting 
kinds  of  alcoholic  delirium  and  chronic  alcoholism.  (See  on  this  point, 
Magnan).*  Those  specially  predisposed  to  the  rapid  incidence  of 
delirium  upon  drinking  are  readily  recognised.    We  are  all  acquainted 

*  "  Patients  specially  predisposed,  who,  when  suffering  from  alcoholic  delirium, 
have  frequent  relapses,  and  a  convalescence  often  interrupted  by  delirious  ideas, 
assxuning  more  or  less  the  form  of  partial  delusion."    Loc.  ciL,  p.  63. 


EVOLUTIONARY    PERIOD    OF    ALCOHOLISM.  307 

with  friends  in  whom  a  single  glass  or  two  of  wine  will  produce 
striking  degrees  of  nervous  instability  ;  just  as  we  recognise  (jthers  in 
whom  hal)itude,  idiosyncracy,  or  other  cause  permits  a  continuous  and 
heavy  intlulgence  in  alcoholic  drinks  with  but  little  obvious  effect. 
It  is  astonisliing  what  large  quantities  may  thus  be  taken  for  prolonged 
periods  with  impunity;  although,  eventually,  the  nervous  centres  must 
undergo  irrecoverable  injury.  A  picture  of  the  so-called  'moderate 
dram-di-inker  from  the  working-classes  of  Sweden,  is  thus  given  by 
Dr.  Huss  : — 

"  He  rises  at  Kve  or  six  in  the  morning,  according  to  the  season  of  the  year,  and 
swallows,  before  going  out,  a  cup  of  coffee  with  a  glass  (2  to  3  ozs.)  of  brandy  in  it. 
He  returns  at  eight  to  breakfast,  which  meal  is  washed  down  with  another  glass 
of  his  favourite  spirits.  At  dinner  he  repeats  the  dose  of  brandy,  and  often  adds 
another  half  glass.  About  five  or  six  p.m.,  when  his  work  is  finished,  another 
glass  is  swallowed ;  and  supper  at  eight  is  concluded  by  a  similar  libation.  During 
the  day,  therefore,  he  consumes  from  five  to  six  glasses  of  brandy,  or  from  ten  to 
fifteen  ounces  of  spirit.  Such  a  mode  of  life  is  far  from  being  regarded  as 
intemperate." 

Dr.  Huss  has  known  some  who  drank  every  day  sixteen  to  twenty 
glasses  of  raw  brandy.  In  the  case  of  J.  C,  the  patient  assured  me- 
he  had  frequently  taken  for  days  together  twelve  to  fourteen  glasses, 
of  raw  whisky ;  nor  did  he  regard  this  as  by  any  means  excessive. 

As  regards  sex,  it  has  been  affirmed  that  chronic  alcoholism  was- 
unknown  amongst  women.  Dr.  Marcet  in  his  intei'esting  tables,*' 
unfortunately,  does  not  help  us,  as  he  excludes  women  from  his 
category,  because  of  the  well-known  difficulty  of  eliciting  truthful 
statements  in  such  cases.  This,  however,  is  certainly  not  a  coi'rect 
statement.  Females  undoubtedly  enjoy  a  remarkable  immunity  from 
the  disease,  as  they  likewise  do  from  general  pai'alysis ;  and  our 
experience  would  lead  us  to  infer  that  Dr.  Huss  gives  a  fair  statement 
of  the  case  in  his  statistics,  wherein  he  finds  but  sixteen  women 
amongst  a  total  of  139  cases  of  alcoholismus  chronicus.  The  case  of 
J/.  T.  is  a  well-marked  instance  of  this  affection  in  women. 

Lastly,  as  regards  affe.  The  statistics  of  Magnus  Huss  fix  the  Ji/th 
decade  as  comprising  the  larger  number  of  cases,  and  the  fourth  decade,, 
as  presenting  a  smpJler  proportion,  his  figures  are  as  follows  : — 

20  to  30  years  of  age,  ......  14  cases. 

30  to  40     ,,     „     ,, 44     „ 

40to50     ,,     ,,     ,, 'u     „ 

50  to  60     ,,,,,, 23     ,, 

00  to  03     ,,     ,,     ,, 1     ,, 

139     ,, 

"  An  inquiry  into  the  influence  of  the  abuse  of  alcohol  as  a  piedisposing  cause 
of  disease."     By  W.  Mircet.     Brit,  d:  Fo;\  Aledlco-Chir.  Ikv.,  1SG2,  Xos.  57-5S. 


308  ALCOHOLIC    INSANITY. 

In  estimating  the  value  of  tliis  taltlc  it  must  1)6  borne  in  niiii<l  tluit 
allowance  must  he  made,  as  in  all  statistical  tables,  not  only  for  the 
varying  population  at  such  period  of  life ;  but,  also  for  the  prolonged 
period  during  which  the  agent  was  at  work  ere  the  malady  was  fully 
evolved  ;  this  latter  consideration  may  have  much  to  do  with  the  high 
number  of  cases  between  the  ages  of  thirty  and  fifty. 

Symptoms  of  Chronic  Alcoholism.— The  functional  disturb- 
ances described  as  present  in  acute  alcoholism  become  interblended 
(if  drinking  be  still  persisted  in)  with  symptoms  indicative  of  struc- 
tural Chang's,  the  injurious  action  of  the  stimulant  becomes  stamped 
upon  the  organism;  and  the  more  freely  the  vice  is  indulged  in,  the 
deeper  is  its  impress.  The  chief  indications  of  such  organic  change 
are,  advancing  and  persistent  mental  enfeeblement,  with  certain 
equally  persistent  senSOry  and  motor  anomalies.  The  general 
enfeeblement  of  the  intellectual  faculties  supervenes  slowly,  but  pro- 
gressively; the  faculties  of  attention,  of  judgment,  and  of  comparison 
suffer;  and  memory  is  specially  implicated.  The  finer  sensibilities  are 
worn  off;  the  subject  is  less  impressionable  and  sympathetic,  less 
charitable,  as  well  as  moi-e  narrowed  and  selfish  in  his  desii'es,  his 
altruistic  sentiments  rapidly  declining.  The  imaginative  faculties  are 
early  affected,  the  higher  emotional  states  are  warped,  and  the  whole 
moral  nature  undei'goes  a  profound  and  serious  change.  "  Apathetic, 
indifferent,  stupefied,  the  chronic  alcoholic  bestows  no  attention  on  his 
person;  he  takes  no  care  of  his  family;  he  is  lowered  in  all  his 
intellectual,  moral  and  social  faculties,  and  finds  himself  yielded 
defenceless  to  the  caprices  of  his  iiistinctive  appetites"  {Magnan).* 
Aural  hallucinations  are  (as  in  the  acute  form)  still  present,  and  are 
now  no  longer  transitory  phenomena,  but  often  of  such  pei'sistence  as 
to  constitute  the  chief  mental  symptom  in  the  earlier  stage  of  chronic 
alcoholism ;  the  victim  to  such  sensoiy  disturbances  suffers  terribly, 
and  not  infrequently  is  driven  to  acts  of  desperate  A'iolence  through 
their  influence.  He  seeks  in  vain  to  release  himself  from  the  intoler- 
able persecution  of  such  voices,  which  blaspheme,  abuse  him,  prompt 
him  to  commit  hideous  crimes,  or  to  utter  obscene  and  revolting 
language.  Pursued  equally  by  night  and  by  day,  he  passes  sleepless 
hours ;  often  he  is  found  sitting  up  in  bed  in  a  state  of  suspicion  or  of 
terror,  declai-ing  his  enemies  are  beneath  his  bed,  or  outside  the 
window  plotting  his  destruction.  At  times  the  expressions  used  by 
his  unseen  foes  are  unintelligible  to  himself,  are  distant  and  scarcely 
audible ;  and  he  distresses  his  mind  much  in  endeavouring  to  attach 
the  proper  meaning  to  such  words ;  at  other  times  they  are  loud  and 
near,  and  he  will  attribute  them  to  those  who  immediately  surround 

*  Op.  cit.,  p.  153. 


AMNESIC    FORMS.  309 

him.  01(1  associates  are  especially  accused  by  tlie  patient  of  thus 
torturing  him  ;  thus,  J.  M'G.  constantly  heard  the  voice  of  a  disreput- 
able girl  with  wliom  he  had  associated ;  J.  J^.  heard  the  voices  of  his 
comrades  and  officers  of  the  regiment  in  which  he  had  served  in  India; 
and,  in  fact,  what  Magnan  states  for  acute  alcoholic  delirium  is  equally 
true  for  the  early  stage  of  chronic  alcoholism — "  The  hallucinations 
have  for  their  subject  either  the  ordinary  avocations,  or  the  dominant 
interest  of  the  moment."  *  This  is  but  an  indication  of  the  change 
wi'ought  in  the  last-evolved  structures  of  the  cortex,  which  are  the 
first  to  be  affected  in  the  dissolutions  induced  by  alcohol.  Thus  it 
was  that  the  first  patient  just  named  (who  had  lived  a  reckless 
dissipated,  and  immoral  life  of  late)  imagined  himself  to  be  surrounded 
by  prostitutes  who  uttered  the  vilest  language,  and  accused  him  of  the 
most  unnatui-al  cx'imes  ;  and  so  it  was  that  the  soldier,  J.  J^.,  thought 
that  he  was  influenced  by  the  persons  with  whom  he  had  recently 
associated  in  his  military  service  in  India. 

The  forms  of  clu'onic  alcoholism  which  usually  present  themselves 
may  be  conveniently  studied  in  three  categories. 

1.  Amnesic  cases  with,  or  without,  delusional  perversion. 

2.  Chronic  delusional  insanity. 

3.  Alcoholic  imbecility  and  dementia. 

1.  Amnesic  FOPms. — Cases  comprised  in  this  category  show  the 
earliest  evidence  of  structural  change  due  to  the  prolonged  use  of 
alcohol ;  they  are  of  most  serious  moment,  as  they  indicate  that  the 
border-land  between  disordered  function  and  real  structui'al  change 
has  been  passed.  We  by  no  means  assert  that  such  cases  cannot  be 
relieved — indeed,  great  relief  is  frequently  experienced  by  the  subjects 
of  alcoholic  amnesia;  but  it  is  not  going  too  far  to  insist  that  absolute 
recoverability  is  rarely  (if  ever)  obtained  from  this  stage  of  alcoholism. 
The  more  notable  feature  characterising  this  class  is  the  peculiar 
failure  in  memory — an  instantaneous  forgetfulness  of  events  which 
have  only  just  occurred.  Every  degree  is  found,  from  slight  reten- 
tiveuess  up  to  a  complete,  and  almost  immediate,  abolition  of  the 
latest  impression.  A  patient  so  afi"ected  forgets  names,  dates,  and 
order  of  sequence,  to  an  almost  inci-edible  degree.  If  a  name  not 
familiar  be  repeated  over  and  over  again,  a  moment's  conversation  will 
often  obliterate  its  memory ;  even  when  told  to  keep  the  word  as  a 
test-word  in  mind — the  recall  fails,  if  the  attention  be  momentarily 
attracted  in  another  direction.  Patients  fully  i-ecognise  their  enfeeble- 
ment  and  often  strive  to  the  utmost  to  overcome  the  difficulty,  such 

*  Op.  cit.,  p.  34. 


310  ALCOHOLIC    INSANITY. 

efforts  eventually  prove  successful,  and  are  suggestive  indications  as 
to  tlie  nature  of  the  lesion. 

J.  F. ,  aged  tliirty-oue,  a  dyer's  labourer;  admitted  in  January,  1S87.  For 
four  inontlis  prior  to  admission,  he  had  l)ecn  strange  in  manner,  restless,  and  of 
vagrant  habits.  He  was  known  to  be  of  intemperate  habits,  but  no  satisfactory 
histoiy  could  be  obtained.  Upon  admission  he  was  free  from  excitement  and 
delusion;  his  intellectual  operations  were  enfeebled,  but  tins  failure  was  evidently 
due  to  the  marked  impairment  of  memory.  The  following  conversation,  held  with 
him  in  the  month  of  February,  illustrates  the  peculiar  defect  alluded  to:  —  "  What 
is  the  day  of  the  week?"  "/  don't  know."  "What  is  the  present  month?"' 
"  Don't  Icnow  for  certain;  November,  as  near  as  I  can  tell."  "  How  long  have  you 
been  here  ?  "  *'  Don't  remember  sleeping  more  than  one  nifjht  here."  "You  gave  me 
the  same  reply  yesterday ! "  "  Did  I?  I  don't  remember;  if  so,  I  suppose  I  have  slept 
here  longer.'"  He  was  now  told  that  the  day  was  Mondaj^  February  7,  1887,  and 
was  requested  to  bear  it  in  mind.  In  a  few  seconds  afterwards  he  was  asked 
the  date,  and  he  replied,  with  some  hesitation,  "November,  188G;  October,  or 
November,  I  don't  know  fairlj\"  He  was  quite  oblivious  to  the  names  of  all  with 
whom  he  had  been  associated  for  some  four  weeks,  and  when  attempts  were  made 
to  impress  them  upon  his  memory,  he  rarel}'  retained  them  be^'ond  one  minute;  and, 
if  any  trivial  question  were  put  meanwhile,  he  became  immediately  oblivious  to  the 
preceding  impression.  Old  familiar  airs  he  sings  correctly,  both  as  regards  intona- 
tion and  words ;  but  any  unfamiliar  sequence,  such  as  the  alliterative  doggerel 
"Peter  Piper,"  he  blunders  over  hopelessly  and  repeatedlj'.  There  is  no  word- 
blindness  or  deafness,  no  tendency  to  ataxic  aphasia ;  his  visual  impressions  are 
correct,  as  tested  for  colours,  and  general  sensibility  is  not  impaired,  as  registered 
by  the  cesthesiometer.  The  dynamometer  registers  for  the  ri^ht  hand  28  kilos. 
pressure,  and  23  kilos,  for  the  left  hand.  After  a  residence  of  three  months,  he 
still  affirmed  that  he  had  only  slept  two  or  three  nights  at  the  asylum.  Eventu- 
ally, this  patient  gradually  improved,  and  a  few  months  later  he  ^vas  discharged 
recovered. 

The  revivability  of  a  former  impression  as  a  resultant  depends  upon 
several  factors;  thus,  there  are — 

1.  The  intensity  of  the  previous  impression. 

2.  The  vig^our  of  circulation  and  nervous  energy. 

3.  The  organisation  of  such  impressions  in  the  establishment  of 

associated  sense-impressions. 

4.  The  vig'our  of  the  faculty  of  attention. 

5.  The  element  of  time. 

Now  in  the  case  with  which  we  are  dealing,  the  intensit}/  of  the  pre- 
vious impi'ession  appears  to  be  of  minor  importance,  but  the  vigour 
of  circulation  and  of  nervous  energy  is  decidedly  at  fault.  Alcohol  in 
its  chronic  results  induces  vascular  paresis  in  various  organs ;  and  the 
brain  and  spinal  cord  are  by  no  means  exceptions  to  this  rule.  Then, 
again,  the  conduction  along  the  nervous  circuit  is  impeded  in  such 
cases  as  px'oved  by  the  retarded  I'esponse  made  to  sensory  stimuli, 


AMNESIC    TROUBLES    IN    ALCOHOLISM.  311 

visual  or  auditory ;  and  this  we  have  more  reason  to  attribute  to  delay 
in  the  sensory  arc  tlian  in  the  'motor  arc,  or  it  may  be  due  to  delay  in 
the  transference  from  the  one  to  the  other.  Such  sluggish  transmission 
can  only  be  regarded  as  resistance  in  the  nervous  arc,  and  as  resulting 
in  a  diminution  of  the  eftective  force  of  the  original  impact  at  the 
periphery.  Hence  it  is,  that  the  organisation  of  such  impressions  by 
the  establishment  of  associative  links,  i.e.,  the  forcimj  of  nevj  nervous 
tracts  into  adjacent  areas  (the  third  factor  mentioned  above),  becomes 
greatly  impeded,  since  this  greatly  depends  upon  the  vigour  of  the 
nervous  current,  and  the  vascular  supply  of  the  part. 

This  failure  in  the  organisation  of  recent  impressions  was  a  prominent 
feature  in  the  case  of  J.  F.,  in  whom  associability  of  ideas  was  most 
strikingly  enfeebled,  and  au  impi'ession  was  received  only  to  be  the 
next  moment  obliterated  ;  very  rarely,  indeed,  did  a  recent  impression 
act  with  such  vigour,  as  to  call  up  associated  states  and  elicit  such  a 
response  as  to  indicate  the  establishment  thereby  of  an  intellectual 
nexus  of  ideas.  Such  organisation  is  greatly  aided  by  the  faculty  of 
attention,  which,  when  directed  towards  the  impression  we  tend  to 
revive,  fosters  the  growth  of  that  associative  process  whereon  a  per- 
sistent and  efficient  memory  is  based.  Thus  it  is  that  slight  distrac- 
tion of  the  mind,  even  momentarily,  by  directing  the  attention  to  any 
other  line  of  thought  will  abolish  the  feeble  tendency  to  organisation 
of  the  original  imjjressions  which  might  otherwise  occur. 

M.  H.  L.,  aged  thirty-six,  married;  family  history  apparently  free  from 
neuroses.  She  maintained  that  her  habits  had  always  been  strictly  temperate. 
Thirteen  months  before  admission,  and  after  her  foiu'th  confinement,  she  suffered 
for  two  days  succeeding  labour  from  convulsive  seizures.  From  that  date  to  the 
present  time  she  had  suffered  from  great  depression  of  spirits,  and  liad  threatened 
to  commit  suicide.  Upon  admission  there  appeared  but  slight  depression,  but  a 
notable  failure  of  memory  was  apparent  with  respect  to  any  recent  circumstance, 
in  so  far  that  she  could  not  recall  the  events  of  her  daily  life  from  hour  to  hour  ; 
could  not  name  those  with  whom  she  was  continually  associated ;  forgot  almost 
immediately  any  event  occurring,  such  as  a  meal,  a  walk,  or  a  conversation,  unless 
such  circumstances  had  been  impressed  by  some  unusual  occurrence.  She  faUed 
to  recall  dates  or  the  duration  of  her  stay  here — believing  she  had  been  at  the 
asylum  but  two  or  three  weeks  after  a  residence  of  eighteen  months.  She  would 
read  persistently  "for  the  sake  of  employing  herself,"  but  confessed  she  could  not 
follow  the  drift  of  any  continuous  narrative,  "as  every  fresh  Ime  seemed  to  blot 
out  the  one  preceding  it."  However  forcibly  she  was  enjoined  to  remember  a 
name  uttered  to  her,  a  moment's  conversation  or  even  a  casual  question  sufficed 
to  obliterate  the  name  from  her  mind.  In  all  other  particulars,  this  patient  waa 
intelligent  and  Avell-informed,  and  her  conduct  rational  and  consistent.  She 
recalled  bygone  events  preceding  her  confinement  very  clearly  ;  but  the  month 
following  the  latter  event  was  to  her  mind  a  complete  blank.  Very  slight 
improvement  took  place  in  her  amnesic  state  during  her  residence  at  the  asylum, 
and  she  was  subsequently  transferred  elsewhere. 


312  ALCOHOLIC    INSANITY, 

The  faculty  of  attention  is  in  these  cases  itself  impaired,  and  the 
mind  tends  to  wander  aimlessly.  Time,  again,  is  an  important 
element  here,  and  in  the  case  of  ./.  F.  it  will  be  noted  that  any  name 
which  he  was  requested  to  bear  in  mind  could  rarely  be  retained  for 
a  longer  time  than  thirty  seconds,  or  a  minute  at  most. 

2.  Delusional  Forms. — A  much  larger  class  is  comprised  by  those 
whose  reasoning  faculties  are  warped,  and  judgment  falsified,  where, 
ixi  fact,  delusional  perversions  form  the  most  notable  feature  of  the 
case.  In  these,  as  in  the  former  class,  anomalies  of  the  sensorial  and 
motorial  apparatus  may  be  present,  and  to  a  much  more  serious 
extent,  exhibiting  a  far  greater  persistency  than  is  observed  in 
acute  alcoholic  delirium ;  and,  in  like  manner,  the  other  intellectual 
faculties  may  be  involved,  the  power  of  attention  enfeebled,  and  the 
faculty  of  recollection  impaired,  yet  the  predominance  of  delusions  is 
the  distinguishing  feature  of  this  class.  The  repeated  storms  which, 
in  the  acute  stage,  have  swept  over  the  delicate  nervous  arrangements 
of  sensory  and  motor  mechanisms  have  damaged  these  mechanisms  to 
an  irremediable  extent,  the  emotional  perturbations,  the  hallucinatory 
phenomena,  ever  changing  and  fleeting  in  the  earlier  stage,  now  begin  to 
assume  a  more  persistent,  a  more  stereotyped  form,  corresponding  with 
actual  structural  change  in  the  sensorium  ;  the  intellectual  aberrations 
evolved  out  of  such  sensory  disorders,  likewise  lose  their  changeful 
nature,  and  take  on  a  more  fixed  and  persistent  character.  The 
exhausting  character  of  the  dischai-ge  from  the  highest  nervous 
mechanism  during  the  acute  stages  has  left  these  centres  in  a  more 
or  less  paralysed  state — the  energy  of  their  cell-elements  is  expended, 
or  escapes  in  streams  too  feeble  to  produce  adequate  results ;  muscular 
tremor  prevails ;  the  whole  life  of  relation  is  affected,  and  its  motor 
activities  cramped  and  restricted  from  this  cause.  The  natural  resis- 
tance to  be  overcome  in  the  motor  centres,  although  not  actually 
increased,  appears  enormously  disproportioned  to  the  capacities  of  the 
volitional  activities,  and  the  subject  consequently  feels  the  encroach- 
ment of  the  environment  which  must  result  therefrom.  The  registry 
of  this  outer  resistance,  and  the  impotence  of  the  will,  must  engender 
distrust,  suspicion,  fear,  and  allied  depressing  emotional  states,  whilst 
the  illusory  and  hallucinatory  states  afibi'd  still  more  tangible  basis 
for  the  fostering  of  a  gloomy,  sus])icious,  distrustful  nature. 

We  have  seen  howj^morbid  sensations  may  be  fostered  and  enormously 
exaggerated  by  the  persistent  direction  thereupon  of  the  attention. 
We  likewise  are  aware  |how  emotional  states  may  be  aroused  to 
unnatural  intensities' by  the  morbid  tendency  of  the  mind  to  dwell 
thereupon  :  so,  delusional  states,  especially  the  hypochondriacal  class, 
are  fostered  by   the   same  influence,  and  the  sense-impressions  upon 


KATURE  OF  THE  DELUSIONAL  PERVERSION.  313 

which  they  may  be  based  are  distorted  to  an  extraoi'dinary  degree. 
Here,  again  (as    indicated    elsevvliore),   with   tlie   decline   of  object- 

consciousness,  there  is  a  corresponding"  rise  of  subject-con- 
sciousness, and  the  conception  is  formed  of  a  hostile  and  aggressive 
environment. 

T.  S.,  aged  fifty-sLx,  married,  commercial  clerk,  admitted  in  January,  1873, 
suffering  from  his  first  attack  of  insanity,  of  fourteen  months'  duration.  He  wa& 
somewhat  above  the  middle  height,  stout,  muscular,  and  well-nourished ;  of  some- 
what swarthy  complexion  ;  hair  black,  turning  grey ;  irides  bluish-grey  ;  pupils 
normal  in  size  and  reaction  ;  malar  and  nasal  capillaries  dilated.  Patient  had  been 
of  intemperate  habits,  but,  although  often  drunk,  could  not  be  called  an  habitual 
drunkard — his  brother  committed  suicide.  He  had  only  recently  been  discharged 
from  a  private  asylum,  where  he  had  resided  for  six  months.  He  was  agitated 
and  suspicious  when  examined  ;  declared  he  had  passed  a  wretched  night,  and 
could  not  breathe  naturally  as  the  "  air  in  the  room  was  exhausted  by  some  means." 
The  instant  he  places  his  head  upon  his  pillow  he  hears  a  whistling  sound,  and  the 
voice  of  his  late  governor  speaks  to  hun  ;  at  times,  the  whistling  and  the  voice 
are  heard  in  the  air  above,  and  even  now  the  voice  is  heard  distinctly  taimting  him 
from  outside  the  window — "Thou 'st  made  a  nice  job  of  thyself,  T.  S.,  by  getting 
in  here."  He  feels  impelled  to  accuse  himself  of  extraordinary  crimes,  such  as 
murder,  poisonmg,  and  a  robbery  of  £50,000,  "  although  he  knows  it  is  not  true." 
The  whistling  under  the  pillow  produces  "an  electric  current,  which  calls  up  a 
feeling  in  his  hands  as  if  he  had  taken  morphia."  When  at  home,  voices  outside 
his  window  were  heard  threatening  his  own  and  his  sou's  life.  Patient  was  a 
highly-intelligent  man,  and  would  talk  for  hours  upon  the  subject  of  his  delusions, 
which  caused  him  much  mental  torture.  The  aural  hallucinations  (although 
present  at  all  times,  more  or  less)  became  terribly  real  to  him  at  night,  and 
deprived  him  of  rest.  He  wrote  a  good  clerical  hand,  and  was  actively  employed 
during  the  first  few  months  of  his  residence  here ;  but,  when  left  to  his  own 
resources,  he  invariably  occupied  himself  in  writing  out  lengthy  epistles  descriptive 
of  the  persecutions  to  which  he  was  subjected.  About  eighteen  months  after 
admission,  he  made  a  desperate  attempt  to  poison  and  hang  himself.  He  had 
secreted  some  putty  and  some  whisky  (which  he  had  bribed  a  patient  on  his 
parole  to  obtain  for  him) ;  these  he  mixed  up  with  a  quantity  of  tobacco-juice, 
and,  having  swallowed  this  strange  compound,  he  suspended  himself  by  some 
knotted  twine  and  a  handkerchief.  Being  a  very  heavy  man  his  M-eight  broke  the 
ligature,  and  his  life  was  saved  after  free  emesis.  He  confessed  to  having  planned 
this  attempt  several  days  previously  ;  his  persecutors  having  threatened  (through 
the  medium  of  a  mysterious  influence  which  he  calls  a  "new  science  ")  to  cremate 
him  alive. 

The  persistency  of  these  delusions  is  evidenced  by  the  followmg  letter  written 
three  and  a-half  years  after  admission  : — 


CONSPIRACY. 
Mr.  F. 

Dear  Sir,— I  beg  you  will  read  the  following  without  prejudice.  .  .  .  My 
first  wife's  sister's  husband,  who  resides  forty  miles  south  of  "London,  is  the 
mventor  of  an  electro-animal-magnetic  machine,  and  other  inventions,  made,  I 
suppose,  somewhat  similar  to  a  camera  obscura,  or  camera  lucida,  both  of  which  or 


314  ALCOHOLIC    INSAXITY. 

all  are  fixed  at  Leeds  or  Wortley  (Imt  I  believe  at  the  last-named  place).  Five  or 
six  persons  whom  I  know  ]>y  tlieir  voices  (but  tiiere  are  many  others  I  don't  know) 
can  see  and  hear  all  that  transpires  in  the  district  (and  to  mj'  own  knowledge) 
within  a  radius  of  thirty  miles,  from  Wortley  ;  they  can  also  tell  (after  having 
applied  the  electro-magnet  to  his  head)  what  any  person  is  thinking,  and  he  is 
compelled  and  cannot  avoid  hearing  all  they  say.  It  is  impossible  that  mesmerism 
or  electro-biology  may  be  combined.  The  mind  of  the  individual  operated  upon 
is  affected  through  a  material  living  agent,  it  may  be  througli  a  material  fluid — 
call  it  electric,  call  it  odic,  call  it  what  you  will,  which  has  the  power  of  traversing 
space,  and  passiuc;  obstacles,  so  that  tlie  material  effect  is  communiaited  one  to 
another.  No  man  or  woman's  life  is  safe  that  they  have  any  ill-feeling  or  hatred 
towards,  so  long  as  those  infernal  inventions  are  allowed  to  be  practised  by  them. 
I  have  been  operated  upon  for  upwards  of  three  and  a-half  years,  by  the  inventor's 
infernal  machines,  by  him,  his,  and  my  first  wife's  relatives,  and  others  who  have 
a  deadly  hatred  towards  me,  and  are  intent  on  schemes  to  shorten  my  life,  their 
object  is  to  make  me  commit  suicide,  then  they  think  they  will  have  their  own 
Avay  in  the  disposal  of  all  I  have,  say  about  £1,500,  which  I  liave  made  by  railway 
shares,  and  saved  out  of  my  wages  (salary)  in  about  forty-one  years.  I  have  no 
doubt,  whatever,  in  saying  that  these  infernal  inventions  have  been  practised  on 
me  from  the  day  I  was  married  to  my  present  wife,  as  I  well  remember  at  times, 
I  was  affected  by  peculiar  voices,  and  whisperings  close  to  my  head,  which  were 
the  causes  of  my  being  so  very  nerveless.  —  1  am,  dear  sir,  yours  truly,         T.  S. 

P.  S.  —  For  the  last  three  and  a-half  years  they  have  sent  a  continual  current  of 
electro-magnetism  (or  be  it  what  it  may)  through  my  head  day  and  night,  I  am 
prepared  to  prove  the  truth  of  what  I  have  written,  also  can  refer  to  parties  who 
will  verify  the  same.  If  you  w'ill  come  over  and  see  me,  I  will  give  you  all  the 
information  I  can  on  the  subject ;  also,  who  some  of  the  parties  are,  and  give  you 
an  idea  where  the  machines,  &c.,  are  fixed.  I  have  been  twice  driven  from  my 
home,  from  fear  of  being  barbarously  murdered.  They  sometimes  send  an  electric 
shock  through  my  head  and  say— "Take  that  to  be  going  on  wnth  .  .  . 
(here  follow  abusive  and  obscene  epithets).  Don't  imagine  I  am  insane  because  I 
■write  this  from  a  lunatic  asylum. — T.  S. 

This  letter  was  further  crossed  by  the  following  postscript : — They  now  say 
they  thouglit  tliey  could  make  me  commit  suicide  in  about  three  days ;  they  never 
thought  it  would  take  them  three  and  a-half  years,  or  they  wouldn't  have  made 
the  attempt.  Had  some  of  the  parties  written  a  similar  letter  to  those  I  have 
written  to  Mr.  B.,  also  to  the  Magistrates  of  Leeds  (six  or  eight  foolscap-pages) 
and  I  had  been  a  party  conspiring  to  deprive  an  innocent  man  of  his  life,  money, 
property,  &c.,  and  had  stolen  a  wooden  case  out  of  any  of  their  houses,  and  put  a 
<lead  Ijody  (corpse)  into  it,  and  buried  it  in  their  gardens,  I  sliould  have  very  soon 
been  in  the  hands  of  the  police,  committed  to  ])rison,  tried  at  the  assizes,  con- 
<lemned,  and  executed,  but  they  and  others  are  allowed  to  do  just  as  they  like — 
there  is  in  Leeds  one  law  for  the  rich  and  another  for  the  poor.  They  arc 
justice's  justice. — T.S. 

Three  years  after  admission  he  made  another  and  nearly  successful  attempt  to 
poison  himself  whilst  employed  in  the  asylum  stores ;  having  secured  and  swal- 
lowed a  consideraljle  quantity  of  marking  ink. 

No  words  could  adequately  describe  the  terrible  mental  torture  to  which 
this  poor  man  was  doomed,  and  although,  at  tunes  (through  the  administration  of 
opiates,  cheerful  society  or  employment,  and  conversation  to  distract  his  mind), 
his  symptoms  were  somewhat  alleviated— the  evening  invariably  found  him  suflFer- 


CASE    OF   T.    S.  315 

ing,  with  rodoubled  force,  from  his  invisible  persecutors.  Like  most  cases  of  this 
category,  lie  exhibited  the  restless  anxiety  to  discover  some  tangible  cause  for  his 
sufferings;  some  plausible  explanation  of  the  diabolical  means  employed  by  his 
enemies.  With  this  object  he  ransacked  every  book,  periodical,  and  newspaper 
he  could  lay  his  hands  upon  ;  and  eagerly  questioned  the  medical  officers  as 
to  the  proV>aliilitios  of  mesmerism,  electro-ljiology,  witchcraft,  odyle,  electricity, 
and  magnetism  being  the  means  employed.  We  well  remember  his  excited  expres- 
sion one  day  when,  handing  us  a  newspaper,  he  indicated  a  passage  bearing  upon 
the  telephone  and  phonograph,  of  which  he  liad  for  the  first  time  heard,  and  which 
lie  convincingly  and  triumphantly  regarded  as  the  solution  to  the  whole  mystery 
of  his  case.  The  possibilities  of  science  are  now  invoked  to  account  for  mysterious 
feelings,  which  long  ago  would  have  been  explained  by  the  patient  as  due  to 
diabolical  agency  or  to  witchcraft.  Demonomania  is  by  no  means  so  common  as  it 
once  appears  to  have  been ;  man's  powers  over  natural  agencies  has  supplanted 
Satanic  agency  from  the  possession  it  held  over  the  minds  of  men  in  explanation 
of  the  weird  symptomatology  of  certain  forms  of  insanity.  —  [(Janes  of  E.  A.  F.  ; 
G.  L.) 

We  have  already  alluded  to  the  resistance  offered  by  the  environ- 
ment to  the  activities  of  the  organism  in  its  life  of  relation ;  to  the 
sense  of  proportionately  increased  resistance  to  motor  energy,  due 
to  the  feeble  initiatory  discharge ;  in  a  certain  sense  this  applies  to  all 
the  mental  faculties  alike.  We  find  amongst  the  delusional  forms  of 
chronic  alcoholism  this  sense  of  obstruction  presented  to  every  form 
of  intellectual  operation.  In  one,  ideation  is  impeded — "  Thought  is 
fettered  and  enslaved  by  the  unseen  agency ; "  in  another,  the  faculty 
of  memory  is  impaired  and  recollection  becomes  painfully  irksome,  and 
this  is  likewise  attributed  to  a  similar  power ;  in  another,  the  expres- 
sive faculty  of  speech  is  restricted,  and  the  patient  declares  that  he  is 
often  compelled  to  say  otherwise  than  he  would ;  he  will  often  add, 
"  Now  I  am  speaking  my  own  thoughts ;  but,  by-and-by,  I  shall  be 
made  to  speak  the  thoughts  of  others."  One  patient  {J.  J^.)  graphically 
describes  his  troubles  thus  : — "  As  I  speak,  the  force  within  me  will 
clip  a  word  in  two,  and  so  wholly  alter  the  meaning  of  what  I  wished 
to  say." 

In  the  case  of  T.  S.,  it  will  be  noticed  that  he  felt  swayed  by  the 
unseen  influence  so  far  as  to  feel  impelled  to  self-accusation  of  crimes 
of  which  he  knew  he  was  innocent.  And  just  as  J.  J^.  believed  that 
he  was  impelled  to  speak  the  thoughts  of  others,  so  he  was  compelled 
to  think  as  they  wished  him,  however  atrocious,  however  sickening, 
obscene,  or  blasphemous  the  line  of  thought.  In  T.  S.,  again,  the 
revolting  language  to  which  he  was  doomed  to  listen — the  horrible 
obscenity  of  speech,  which  he  hesitated  to  record  in  writing — was  a 
notable  feature,  and  was  equally  prominent  in  the  case  of  J.  M^G. 
All  these  are  instances  of  the  enthralment  of  the  individual  faculties 
of  the  mind,  leading  to  the  sense  of  an  invasion  by  an  antagonistic 


316  ALCOHOLIC    INSANITY. 

environmental  ajj;ency  ;  the  noxious  character  of  which  is  inversely 
proportioned  to  the  growing  sense  of  helplessness  and  incapacity  of  the 
organism.  The  patient,  J.  S.,  died  of  an  intercurrent  affection,  and, 
as  a  sad  sequel  to  his  history,  his  only  son  was  admitted,  at  the 
age  of  forty,  suffering  from  delusional  insanity,  as  the  result  of 
alcoholic  excess.  He  had  had  repeated  seizures  of  delirium  tremens ; 
had  squandered  a  large  sum  of  money  away  by  his  dissipated  habits ; 
and  was,  on  admission,  the  subject  of  phthisis,  to  Avhich  he  succumbed 
in  five  months  time.  His  history  was  one  of  persistent  hallucinations 
and  gloomy  delusions,  in  which  he  often  thought  himself  accused  of 
atrocious  crimes.  He  was  determinedly  suicidal,  refused  food  for 
a  long  time,  and  struggled  desperately  against  its  compulsory  admin- 
istration. He  was  surly,  suspicious  of  all  alike,  could  be  induced  to 
talk  but  little  upon  the  subject  of  his  delusions,  and  never  volunteered 
any  reference  to  them  unless  repeatedly  prompted. 

These  cases  of  delusional  hisanity  due  to  chronic  alcoholism  fall  into 
several  natural  groups  corresponding  with  the  nervous  centres 
primarily,  or  more  prominently,  implicated.  Thus,  there  are  those  in 
whom  sensorial  anomalies  preponderate,  and  in  tliese  the  centres  of 
special  sensation,  and  chiefly  the  auditory,  may  be  implicated ;  or  the 
centres  for  the  organic  sensations  emanating  from  the  various  viscera ; 
or  the  centres  for  the  generative  organs  and  the  sexual  instincts ;  all 
leading  up  to  delusional  perversions.  There  are  those  in  whom  the 
intellectual  operations  are  specially,  and  often  primarily,  affected  when 
the  delusions  (although  often  associated  with  aural  hallucinations  or 
hallucinatory  states  of  other  special  or  general  sensations)  are  not 
necessarily  evolved  out  of  these.  Their  special  character  consisting 
in  a  primary  change  in  the  centres  of  other  intellectual  operations,  and 
the  resistance  offered  to  the  diminished  mental  energy,  is  registered  as 
the  immediate  antagonism  of  a  malevolent  power,  which  has  gained 
access  to  the  organism.  Besides  these  two  categories  there  is  the  class 
already  alluded  to  of  the  primary  amnesic  form,  in  which  the  faculty  of 
recollection  is  the  one  mure  prominently  or  exclusively  affected. 

In  the  primarily  sensorial  forms  we  find  aural  hallucinations 
preponderate ;  and  although  other  senses  (more  often  those  of  taste, 
smell,  and  general  sensation)  may  be  likewise  disturbed,  in  most 
cases  the  auditory  disturbance  is  the  only  anomaly  complained  of. 
The  phenomena  observed  may  embrace  every  possible  combination  of 
articulate  or  inarticulate  sounds.  ]f  voices  be  heard,  they  may  be 
distant  and  scarcely  audible,  or  near  and  loud,  or  in  close  propinquity 
may  whisper  in  the  sufferer's  ears  ;  they  may  be  above,  below,  on 
the  right  or  the  left,  and  may  be  referred  to  casual  passers-by,  to 
animals,  or  to  birds.     Thus,  one  patient  heard  the  sparrows  talking  to 


VISCERAL    ILLUSIONS.  317 

him  as  tlioy  flitted  to  and  fro ;  another  was  addressed  by  the  crows 
as  they  flew  past  him  ;  but,  the  voice  was  the  voice  of  human  beings 
wliom  he  recognised  as  his  enemies.  Certain  French  writers  have 
alluded  to  bilateral  hallucinations  in  which  the  patient  hears  with 
one  ear  threatening,  denouncing,  or  revolting  language  ;  and  with  the 
other  encouraging,  kindly,  and  conciliatory  words  ;  this  condition  we 
have  never  met  with  in  alcoholics.  In  all  such  cases,  the  malign 
influence  makes  itself  felt  in  discouraging  or  alarming  terms. 

A  form  of  visceral  hallucination  is,  however,  often  present, 
which  is  of  great  interest  as  indicative  of  the  manner  in  which  new 
but  morbid  groupings  arise  within  the  sensorium.  It  is  that  of  the 
epig'astriC  voice,  in  which  a  sensation  felt  at  the  epigastrium  is 
•  often  spoken  of  as  a  "  voice,"  which  the  patient  describes  as  not  an 
auditory  perception  but  still  "a  voice"  which  makes  itself  understood, 
and  by  which  he  feels  himself  impelled  to  act — this  was  the  case  vrith 
J.  W.  It  would  appear  that  a  centric  disturbance  projected  to  the 
epigastric  region  is  associated  in  some  way  with  a  disturbance 
impressive  of  the  auditory  centres  of  speech ;  and  that  the  associated 
sensory  change  is  referred  in  both  cases  to  the  same  site.  In  fact,  it 
may  be  often  observed  that  any  morbid  sensation,  cutaneous  or 
visceral,  will,  in  like  manner,  determine  the  direction  from  which  an 
aural  hallucination  appears  to  emanate ;  both  phenomena  being 
referred  centrally  to  the  same  category  of  maleficent  agencies. 

An  important  class  is  comprised  of  those  whose  characteristic 
delusions  and  illusions  are  those  of  the  sexual  feeling's  and 
instincts.  A  large  number  of  alcoholics  exhibit  some  degree  of 
perversion  of  the  sexual  feelings^  referred  by  them  to  an  antagonistic 
agency ;  but  we  more  especially  allude  to  those  who  exhibit  this 
perversion  as  the  ruling  spirit  of  their  insanity.  Out  of  such  cases, 
the  most  astounding  delusions  are  begot.  A  typical  case  who  has 
been  for  years  an  inmate  of  the  West  Riding  Asylum,  refers  all  his 
morbid  sensations  to  the  generative  system,  which  he  believes  to  be 
operated  upon  by  various  agencies — electricity,  poisons,  caustic,  red- 
hot  iron,  and  elaborate  mechanical  contrivances  worked  by  magnetism, 
which  have  been  invented  by  his  unseen  enemies  with  the  object  of 
rendering  him  miserable  and  ultimately  insane.  Impressed  with  the 
notion  that  these  agencies  afiect,  not  only  himself,  but  thousands  of 
others  who  are  confined  in  asylums,  he  writes  manuscript  by  the  yard, 
revealing  his  feelings  to  the  Government,  and  describing  the  various 
ingenious  and  diabolical  means  used  for  such  purposes.  He  sketches 
large  figures  in  coloured  crayons,  representing  the  human  form  in  both 
sexes,  delineating  their  anatomical  structure  according  to  his  own 
notions,  in  which  the  generative  apparatus  occupy  a  most  conspicuous 


318  ALCOHOLIC    INSANITY. 

position,  and  in  which  are  mapped  out  the  course  of  the  "  electric 
Huid,"  and  the  structures  which  are  supposed  by  him  to  be  concealed 
within  the  body  for  such  purposes  of  torture. 

During  his  relapses  of  excitement  he  recorded  (on  a  roll  of  paper 
measuring  a  dozen  yards  in  length,  both  sides  closely  written  upon) 
his  feelings  and  maledictory  comments  dedicated  to  his  persecutors. 
The  eflusion  throughout  was  couched  in  the  most  obscene  and  revolt- 
ing language  obtrusively  exposed ;  in  his  calmer  moments,  no  one 
could  be  more  decorous  and  punctilious  in  his  behaviour  and  conversa- 
tion. The  case  of  J.  M^G.  is  allied  to  this ;  in  him,  also,  the  sexual 
organs  were  the  subject  of  delusional  perversions.  Sexual  hallucina- 
tions at  night  were  frequently  complained  of;  and  his  female  persecutor 
was  believed  to  act  prejudicially  upon  his  system  from  a  distance 
through  the  medium  of  a  "  mirror."  He,  moreover,  heard  lewd, 
lascivious  utterances  from  old  associates,  who  imputed  to  him  various 
unnatural  crimes. 

E.  A.  F.,  aged  fifty,  married,  printer  by  occupation;  a  tall,  powerfully- built , 
muscular  man,  somewhat  prematurely  aged,  with  a  suspicious,  furtive  look,  a 
dusky,  sallow  complexion;  pupils  active,  the  right  somewhat  the  larger  of  the 
two;  no  facial  or  lingual  tremor;  no  impairment  of  articulation.  The  heart's 
sounds  were  exceedingly  weak,  but  there  was  no  murmur,  no  intermission,  and 
the  pulse,  which  was  very  feeble,  was  regular.  No  insanity  was  traceable  among 
his  antecedents,  no  history  of  neurosis  or  ancestral  intemperance.  Patient  had 
long  been  addicted  to  excessive  drinking. 

Upon  examination  he  betrayed  much  nervous  agitation,  stared  at  the  ceiling 
and  walls,  declaring  the  room  was  surrounded  by  instruments,  whereby  people  in 
Leeds  and  Bradfoi'd  could  hear  all  that  he  said;  certain  perforations  in  the 
wainscotting  he  asserted  were  telephones ;  the  bed  he  lies  upon  is  electrified,  and 
he  even  now  feels  the  current  passing  through  him.  At  his  own  home  a  telephone 
wire  ran  beneath  the  floor  of  his  room,  and  upon  placing  the  legs  of  his  chair 
parallel  with  this  wire,  he  could  himself  feel  the  electric  current;  people  in 
adjacent  houses  constantly  spoke  audibly  through  the  walls  of  his  house;  they 
were  in  intrigue  with  his  wife,  whose  fidelity  he  distrusted.  He  found  that  she 
used  secret  signs — e.g.,  folding  her  shawl  in  a  certain  manner  meant  that  he 
slept,  &c. ;  and  so  she  communicated  with  his  enemies. 

Memory  was  unimpaired  ;  his  attention  good  ;  and  his  replies  were  prompt ;  he 
freely  admits  alcoholic  excess. 

Sept.  25. — Nine  days  after  admission — still  very  suspicious;  firmly  believes  his 
wife  conceals  herself  in  the  building,  and  goes  about  looking  for  her.  Thirty 
grains  of  chloral  given  nightly  to  relieve  insomnia. 

Oct.  3.  — Is  convinced  his  tobacco  is  poisoned ;  hears  voices  of  unseen  persons. 
The  sounds  issue  through  the  ventilating  outlets  near  the  ceiling.  "Cannot  you 
hear  them  now  ? "  Manner  very  suspicious ;  requests  a  private  interview,  and, 
when  conversing,  frequently  expresses  the  fear  that  he  is  overheard. 

Oct.  10. — Aural  hallucinations  constant  during  his  waking  hours;  asserts  that 
he  hears  his  wife  upstairs  calling  out,  "Fool,  fool,  fool!"  is  quite  convinced  it 
is  she,  and  if  his  iuterlocutor  would  but  spend  half-an-hour  with  him,  he  would 


CASE    OF    CHRONIC    ALCOHOLISM.  319 

also  be  convinced;  heard  his  niece  this  morning,   and  his  daugliter's  voice  last 
night.     He  made  a  most  violent  attack  iipon  an  attendant  later  on. 

Nov.  II.— "They  galvanise  all  the  chairs,  and  the  current  goes  through  me 

strongly." 

/)ec.  7. — Eemarked  to  an  attendant,  who  opened  his  door  this  morning,  "  Now 
or  never!  "  and  followed  him  closely,  it  is  not  certain  with  what  intentious. 

Jan.  19. — "Hears  attendants  in  the  rooms  overhead  making  a  huzzing  noise 
and  talking;"  hut  does  not  hear  what  they  say. 

fg})^  1. — No  change  of  late;  quiet,  well-conducted,  and  sleeps  well;  fancied  he 
heard  a  sound  last  night  like  a  female  voice  talking  to  him  through  the  ventilators 
of  his  room;  and  feels  something  like  an  electric  current  running  through  his  right 
side  to-day— he  often  feels  it;  fully  convinced  that  wires  convey . electricity  all 
through  the  wards;  the  voices  are  not  sounds  in  reality,  but  "  thoughts  conveyed 
by  electricity. " 

May  4. — Discharged  "  relieved,"  at  the  urgent  request  of  his  friends. 

He  remained  fairly  well-conducted  and  temperate  for  twelve  months,  then 
relapsed  into  his  drinking-habits,  which  induced  an  exacerbation  of  his  mental 
symptoms,  leading  to  a  second  admission  eighteen  months  later.  The  hallucina- 
tions had  become  far  more  distressing ;  and  whilst  walking  in  the  open  streets,  he 
heard  voices  of  people  miles  away  talking  to  him  ;  suspicions  against  wife  and 
children  returned  with  redoubled  force;  he  accuses  the  former  of  the  grossest 
immorality ;  had  been  dangerously  violent  to  her,  and  had  once  nearly  strangled 
her.  The  night  preceding  his  admission  here,  he  had  driven  wife  and  children  out 
of  doors,  threatening  that,  if  they  did  not  leave,  he  would  murder  them  all. 

His  subsequent  history  was  but  a  repetition  of  what  had  preceded  this  attack, 
and  he  left  the  asylum  relieved  in  the  course  of  seven  months. 

Then  we  have  the  class  of  cases  where  disturbances  of  cutaneous 
sensibility  lead  to  delusional  concepts  of  a  mysterious  principle, 
known  or  unknown,  acting  upon  the  body.  Thus,  in  the  case  of  G.  L., 
the  room  was  surrounded  by  invisible  tubes,  from  which  issued  currents 
of  air  producing  electricity,  and  affecting  his  body  and  limbs — con- 
torting and  twisting  them  into  various  attitudes,  and  causing  him 
much  agony ;  often  leaving  him  weak  and  prostrate  upon  waking  in 
the  morning.  The  unseen  fluid  enters  his  ears,  and  aff"ects  his  brain  ; 
but  his  malignant  enemies  always  keep  "  prudently  at  a  distance." 

A  very  special  form  of  delusion,  already  alluded  to  and  illustrated, 
becomes  elaborated  in  such  cases  as  that  of  J.  B.  Here  the  resistance 
met  with  by  the  organism  appears  chiefly  to  aftect  the  intellectual 
operations,  and  in  a  very  direct  manner.  The  faculty  of  thought  and 
speech  become  impaired,  and,  as  the  victim  believes,  by  the  direct 
operation  of  a  power  which  has  gained  access  to  his  bi-ain ;  which  rules 
his  thoughts  and  dictates  his  very  utterances.  In  such  cases,  where  (as 
in  thiit  of/.  B.)  no  sensory  hallucinations  have  been  experienced,  we 
may  safely  infer  that  the  centres  of  the  intellectual  operations  are 
primarily  diseased.  Thus  we  find  attention,  ideation,  memory,  volition 
in   varying   degrees   afi"ected   in   this   class    of  cases,   and    delusional 


320  ALCOHOLIC    INSANITY. 

concepts  evolved  out  of  tlie  resistance  which  is  engendered  by  such 
failure. 

Evolutions  of  Psychical  Phenomena.— A  case  of  chronic  alco- 
holism of  the  purely  sensorial  form  is  obviously  not  one  of  alcoholic 
insanity  ;  and  it  becomes  an  interesting  and  ijuportant  point  to  trace 
the  progress  of  the  affection  from  the  sensory  areas  pure  and  simple 
to  the  planes  of  intellectual  operations — to  recognise  the  gradual 
overstepping  of  the  boundary  line  where  intellect  itself  becomes 
involved  and  the  case  relegated  to  the  category  of  the  insane.  AVith 
this  object,  let  us  study  the  nature  and  effects  of  the  sensorial  distur- 
bances. The  hallucinatory  phenomena  are,  as  we  know,  presumed  to 
be  due  to  certain  abnormal  discharges  from  the  sensory  areas  of  the 
cortex. 

Nature  of  the  Discharge. — If  the  nervous  discharge  be  carefully 
considered  we  shall  find  it  one  of  high  tension;  sudden  explosive  onset; 
rapid  escape;  irregular  or  fitful  occurrence.  The  centres  are  in  a  state 
of  extremely  unstable  equilibrium — a  state  of  sensory  hypersesthesia 
prevails.  When  such  unstable  centres  discharge  themselves,  one  or 
more  of  several  results  may  occur.  In  the  first  place,  as  indicated  by 
Dr.  Hughlings-Jackson,  the  discharging  centre  exhausts  itself — is,  for 
the  time  being  (in  the  case  of  the  sensory  area),  less  imj^ressionahle — 
and  has  assumed  a  state  of  molecular  stability.  In  the  second  place, 
the  centres  subordinate  to  the  paralysed  centres  rise  into  uncontrolled 
activity.  In  the  third  place,  the  discharge  takes  a  certain  course  and 
produces  certain  results. 

(a.)  Thus,  it  may  react  along  a  motor  tract  and  issue  in  active 
movement ; 

(h.)  It  may  dift'use  itself  in  sensorial  realms,  producing  emotional 
perturbation ; 

(c.)  It  may  involve  nervous  mechanisms  subservient  to  the  intel- 
lectual sphere  of  mind,  and  active  ideation  may  be  aroused  thereby. 

Whichever  course  it  takes,  whether  one  or  the  other  or  many,  it  is 
to  be  observed  that  the  point  for  us  to  consider  is  the  forcing  of  other 
and  distant  nervous  tracts  which  are  hereby  rendered  more  permeable  to 
such  discharges  in  future. 

Hallucinations  a  determining"  Factor  of  Morbid  Ideation. — 

Let  us  revert  to  our  original  conception  of  the  phases  of  object-  and 
subject-consciousness.  The  sensory  fibres  are  the  channels  for  those 
pulsatile  tremors  which  arouse  the  sensory  cortex  into  activity  coinci- 
dent with  the  presentative  states  of  consciousness.  In  other  words, 
these  vibratile  thrills,  transmitted  up  to  the  centres  of  general  and 
special  sensation,  constitute  the  raw  material  of  object-consciousness. 


HALLUCINATIONS    A    FACTOR    OF    MORBID   IDEATION.  321 

In  alcoholism  we  say  there  is  a  general  augmentation  in  nerve-resist- 
ance, both  in  sensory  and  motor  channels. 

In  the  sensory  nerves  it  is  indicated  by  the  tingling,  prickling,  and 
formication  whicli  follow  the  hyperjesthetic  stage  of  the  cutaneous 
surface — all  of  which  phenomena  are  probably  due  to  the  broken-up 
current — the  nervous  impulse  interrupted  by  augmented  resistance 
— whereby  successive  shocks  are  no  longer  fused  into  a  single 
impulse.  Hence,  excitations  from  the  periphery  do  not  reach  these 
centres  in  the  normal  state;  and  a  decline  in  object-consciousness  occurs, 
with  a  corresponding  rise  in  suhject-consciousness.  The  centres  them- 
selves are  in  a  state  of  hypersesthesia,  of  extreme  instability,  and  their 
intermittent,  spasmodic  discharges  must  take  some  determinate  course. 
The  discharge  from  the  centres  of  special  senses  (which  is  the  physical 
side  of  a  hallucination)  may  diffuse  itself  along  lines  of  least  resistance 
in  the  sensory  realms,  discharging  the  numerous  extremely  minute 
nerve-granules  (the  reservoirs  of  feeling)  found  in  these  regions  ;  and 
issuing  in  emotional  states  which  require  but  slight  impact  for  their 
arousal.  On  the  other  hand,  if  the  energy  of  the  sensory  discharge 
be  sufficiently  great  it  will  break  through  lines  of  great  resistance  and 
flood  the  channels  of  those  centres  which  have  for  their  psychical 
correlate  the  ideational  faculties ;  or,  overcoming  the  resistance  of 
motor  nerves,  issue  in  determinate  movements. 

In  alcoholism  the  specific  resistance  of  the  afferent  and  efferent  fibres 
is  augmented ;  the  former  resulting  in  a  decline  in  ohject-consciotisness  ; 
whilst  the  centric  discharges  opposed  by  the  latter  originate  the 
depressing,  emotional  states  associated  with  feelings  of  environmental 
antagonism,  which  is  so  notable  a  feature  in  this  affection.  Nor  is  the 
resistance  ahead  other  than  a  favourable  condition;  for,  by  this  means 
emotional  states  form  a  safety-valve  for  unstable  discharging  centres — 
often  by  motor  lines,  and  so  relieve  the  plane  of  more  purely  intellectual 
operations  from  the  fatal  results  of  the  inrush  of  morbid  discharges. 
It  is  only  when  the  barrier  of  resistance  partially  gives  way  that  the 
development  of  delusional  conceptions  becomes  possible. 

Continued  discharges  from  these  sensory  areas  eventually  break 
through  this  barrier  of  resistance,  but  only  in  certain  determinate 
lines,  which  become,  so  to  speak,  channelled  out,  and  more  and 
more  pervious  by  the  repetition  of  discharges  along  the  same  tract. 
Thus  it  is,  that  in  the  psychical  side  we  find  that  certain  hallucinations 
eventually  beget  certain  determinate  lines  of  thought  corresponding 
thereto ;  that  imagination  becomes  tinctured  by  the  distressing  hallu- 
cination and  gloomy  emotional  background ;  and  that,  thus,  the 
spheres  of  the  intellectual  operations  become  pervaded  by  such 
agencies,  and  strong  contrasting  feelings  and  ideas  arise,  overbalancing 

21 


322  ALCOHOLIC    INSANITY, 

the  former  intellectual  being ;  hence,  the  genesis  of  delusional  states. 
The  forcing  of  such  tracts,  or  the  more  pervious  channelling  caused  by 
energetic  or  oft-repeated  discharge,  may  often  be  witnessed  in  health — 
note  the  continual  recurrence,  despite  our  inclination,  of  a  song  we 
have  lately  heard,  or  been  impressed  with  ;  and  the  incontrollable 
tendency  at  times  to  hum  or  whistle  over  a  tune  which  we  in  vain 
attempt  to  dismiss  from  the  mind.  Again,  the  tormenting  recurrence 
of  a  line  of  thought,  after  prolonged  and  fatiguing  mental  work, 
which  so  often  deprives  a  student  of  his  night's  rest.  This  persistence 
of  sensory  and  ideational  excitation  is  due  to  a  too-pervious  channel 
established,  and  loss  of  higher  controlling  centres;  and  it  can  only  arise 
after  discharge  from  the  uppermost  series,  leaving  these  latter  exhausted. 
So  in  these  morbid  states  certain  tracts  become  permeated,  to  the 
exclusion  of  others,  by  the  powerful  but  intermittent  discharge  from 
sensorial  realms,  and  unstable  molecular  arrangements  are  built  up  in 
the  substrata  of  the  ideational  centres. 

Sensory  troubles. — An  early  symptom  in  chronic  alcoholism,  is 
disordered  common  cutaneous  sensibility,  and  tactile  sensibility ;  ex- 
altation of  both  usually  preceding  the  various  modifications,  their 
diminution  or  abolition.  Tingling,  prickling  sensations  are  often  felt, 
and  formication  is  especially  frequent ;  the  patient  feels  as  though 
insects  were  crawling  beneath  the  skin — over  the  thigh  and  gluteal 
regions,  and  gradually  extending  to  the  trunk  and  arms  —  until 
the  feeling  is  at  times  quite  intolerable :  it  indicates  that  a  change 
is  progressing  in  the  sensory  trunk  and  centres.  Patches  of  hyper- 
aesthesia  are  often  noted,  as  in  the  wrist  of  the  patient  {J.  J^.), 
where  tactile  sensibility  is  greatly  exalted  ;  the  site  is  also  equally  one 
of  hyperalgsesia.  The  variety  of  hyperalgsesia,  when  contact  causes  a 
sensation  as  of  burning,  or  of  a  sharp  cutting  edge,  is  also  a  frequent 
phenomenon,  and  in  one  patient  the  peculiar  modification  called 
by  Fischer  2^olycesthesia,  in  which  one  point  is  recognised  as  two 
or  three  points,  was  observed.  Shooting  pains  are  prevalent  in 
advanced  cases,  the  pain  being  not  infrequently  associated  with 
muscular  shocks,  the  patient  often  regards  them  as  due  to  electric 
discharges.  The  excessive  exaltation  of  the  sense  of  pain,  associated 
with  spasms  and  cramps,  leads  to  ideas  of  the  limbs  being  torn, 
wrenched  oflf  and  mutilated.  Later,  we  find  numbness  and  blunting 
of  general  sensibility,  passing  into  areas  of  complete  anaesthesia  (often 
with  an  extreme  degree  of  vaso-motor  paresis)  which,  beginning  at 
the  tips  of  the  fingers  and  toes,  creeps  up  the  dorsal  aspect  of  the 
limbs. 

Motor  Symptoms. — The  group  of  symptoms  described  under  the 
head  of  sensorial  anomalies,  though  highly  characteristic  of  chronic 


SENSORIAL    AND    MOTORIAL    DISTURBANCES.  323 

alcoholism,  is  by  no  means  necessarily  distinctive  of  this  affection,  since 
such  symptoms  may  arise  (individually  or  collectively)  in  other  nervous 
diseases :  the  same  remark  applies  also  to  the  mental  anomalies 
exhibited  by  alcoholics.  Ordinary  forms  of  delusional  insanity  often 
show  the  selfsame  symptomatology,  the  dementia  of  later  stages  of 
alcoholism  being  scarcely  distinguishable  from  other  non-alcoholic 
states  of  mental  decadence.  Even  the  amnesic  type  referred  to,  may 
be  recognised  as  sequent  occasionally  to  other  convulsive  neuroses. 

It  is  in  the  motor  anomalies  that  we  find  the  most  definite  indica- 
tion of  an  alcoholic  etiology,  for  they  especially  present  a  distinctive 
group  rarely,  if  ever,  exhibited  by  other  neuroses  than  the  alcoholic. 
Perhaps  too  much  emphasis  has  been  laid  upon  the  sensory  and 
mental  disturbances  of  chronic  alcoholism  to  the  exclusion  of  the 
motorial  in  the  diagnostic  indications  usually  appealed  to  ;  for,  cer- 
tainly, the  motor  group  are  the  "tell-tale"  symptoms  which  most 
clearly  indicate  the  agencies  which  have  been  at  work.  It  is  not,  how- 
ever, by  the  grouping  of  such  symptoms  (whether  sensorial,  mental,  or 
motorial)  that  we  shall  be  chiefly  aided  in  eliciting  an  alcoholic  factor; 
we  must  chiefly  rely  upon  the  historical  aspect  of  our  case — the  mode  of 
evolution  of  such  symptoms,  and  the  tendency  of  the  disease  towards 
fresh  nervous  implications.  Here,  especially,  do  we  recognise  the 
scientific  process  pursued  by  Magnan  in  his  classical  work,  when  indi- 
cating the  tendencies  of  alcoholism  to  pass  into  dementia,  or  general 
paralysis.  The  tendency  alluded  to  more  particularly  at  this  phase, 
and  upon  which  we  do  not  think  suflcicient  emphasis  has  been 
placed,  is  this :  the  morbid  process  due  to  alcoholism  evolved  in 
sensory  areas  ever  tends  to  he  translated  into  the  motor  realms  of  the 
brain,  establishing  necessarily  a  co-existent  disturbance  in  what  we 
may  speak  of  as  the  motor  realms  of  the  mind.  However  acute,  however 
persistent  may  be  the  sensorial  disturbance,  we  shall  always  recognise 
a  tendency  towards  this  tPanslation  in  physico-mental  terms — the 
delusional  distortions  being  often  nothing  more  than  mere  symbols 
of  motOP  enfeeblement  which  may  not  be  so  obtrusive  a  symptom 
to  the  observer. 

J.  R.,  aged  thirty -four,  single,  a  blacksmith;  admitted  November,  1883.  He 
had  previously  been  an  inmate  from  August,  1882,  to  March,  1883,  and  was  then 
discharged  as  relieved.  Five  years  ago  he  suffered  from  a  blow  on  the  head  by  a 
stone  in  a  quarry  falling  upon  him.  Upon  leaving  the  asylum  he  went  to  work  in 
a  colliery,  but  was  soon  thrown  out  of  employment  by  a  pit  accident,  when  he 
returned  to  irregular  habits  of  life,  drinking  very  heavily,  and  speedily  developed 
mental  symptoms.  He  became  violent,  and  talked  much  of  the  sim,  moon,  and 
stars.  His  sister  stated  that  patient's  father  was  a  notorious  drimkard,  that 
three  of  patient's  brothers  were  excessive  drinkers,  and  that  two  others,  as  well 
as  a  sister,  had  died  of  phthisis.     The  mother  and  her  parentage,  however,  were 


324  ALCOHOLIC  insanity. 

healthy  and  temperate.  Patient  heg<an  drinking  raw  spirits  at  the  age  of 
sixteen,  when  employed  in  "bottling"  at  a  spirit-store.  Since  this  time  he  has 
wandered  to  and  fro  about  the  country,  often  lost  .sight  of  for  years  l)y  his 
relatives  ;  but  he  remained  to  the  end  a  very  heavy  drinker.  At  times  he  would 
reappear  amongst  his  relatives,  shocking  them  with  his  dissolute  habits  ;  secreting 
spirits,  and  drinking  by  the  pint  daily,  in  spite  of  every  effort  to  restrain  him. 
During  his  second  residence  at  the  asylmn  he  was  excited,  incoherent,  incessantly 
garrulous,  restless,  and  irrational ;  "  has  the  sun  and  moon — lialf  the  moon  in  his 
head."  He  was  destructive  of  clothing.  He  had  a  somewhat  imbecile  expression, 
was  good-humoured,  jocose,  and  talked  recklessly.  His  face  was  thin,  complexion 
earthy,  cheeks  and  nose  dusky ;  the  pupils  were  equal — consensual,  reflex,  and 
associative  movements  were  active.  There  was  no  defect  of  articulation ;  no 
muscular  tremor ;  was  of  spare  habit,  weighing  126  lbs. ;  height,  5  ft.  7  ins. 
Thoracic  and  abdominal  systems  appeared  normal. 

Nov.  29. — Six  days  after  admission — excited,  destructive,  yet  his  bodily  strength 
keeps  up,  and  he  takes  food  well.     Hyoscyamine  (^  grain)  ordered. 

Dec.  4.  — Sleeps  well,  and  is  improved  mentally  ;  more  rational  and  coherent. 
Dec.   19. — More  excited,  mischievous,  negligent  in  habits,  restless,   untidy  in 
dress  ;  hides  anything  he  can  secure  ;  sleeps  well ;  appetite  good. 

Some  four  months  later  he  still  continues  maniacal ;  grotesque,  pretends  to  be 
timid  and  humble,  picks  the  patient's  pockets,  upsetting  all  the  ward,  and  delighted 
with  the  mischief  he  has  done.  He  remained  for  twelve  months  an  inmate,  and 
was  then  discharged — "recovered." 

Upon  his  tldrd  admission  (February  13,  1886)  he  was  excited,  wild,  and  threat- 
ened to  cut  his  own  throat  or  strangle  himself.  He  was  quite  incoherent.  He, 
however,  soon  fell  into  his  usual  noisy,  garrulous,  jocular  humour ;  inclined  to 
much  merriment  and  to  the  use  of  obscene  terms  ;  talked  much  of  the  other  sex, 
and  had  apparently  sexual  hallucinations.  He  was  in  incessant  movement, 
undressing  himself,  gnawing  at  his  clothing,  gesticulating,  and  grimacing  like  a 
monkey  ;  no  grandiose  notions.  The  pupils  were  equal,  normal  in  reaction  ;  deep 
and  superficial  reflexes  were  normal ;  he  was  thin  and  reduced  ;  the  heart  seemed 
healthy,  but  the  vessels  were  corded. 

Feb.  20.  — Excited,  restless,  in  and  out  of  bed  constantly ;  obscene,  incoherent. 
March  2. — Quieter,  yet  noisy  at  nights  ;  degraded  and  obscene — masturbates. 
March  9.  — Has  a  comic  expression ;  acts  like  a  monkey  ;  accosts  eveiyone  in 
flippant  terms  ;  asks  for  better  clothing,  yet  destroys  all  he  secures. 

June  12. — Makes  random  statements  ;  says  he  has  been  here  twenty-four  years. 
He  now  works  regularly,  but  still  has  the  same  simian  look  and  habits. 

Aug.  16. — No  notable  dementia  ;  his  conversation  is  sonaewhat  childish  ;  health 
much  improved. 

Jan.,  1887. — He  left  the  asylum  "recovered." 

He  was  admitted  for  the  fourth  and  last  time  in  November,  1887.  At  this 
date  he  was  in  a  state  of  continuous  maniacal  excitement,  usually  stark  naked  in 
his  room,  crawling  upon  hands  and  knees,  degraded  in  his  habits,  and  requiring 
manual  feeding.  He  was  still  in  a  jocular  humour,  laughed  much,  and  gave 
absurd  random  replies ;  snatched  things  out  of  the  attendant's  hands,  grimaced 
apishly,  and  gesticulated  much.  He  was  very  tliin,  his  muscles  flabby ;  facial 
capillaries  much  dilated  ;  pupils  were  equal  and  active  ;  deep  reflexes  normal. 

Dec.  2. — Has  become  very  suddenly  feeble,  totters  much  in  his  gait,  and  is  iticlined 
to  ''double-up  ;"  is  still  maniacal,  but  mutters  more  to  himself  ;  tongue  somewhat 
brown. 


CASE   OP  J.   R.  325 

Dec.  9. — Can  just  support  himself  with  his  feet  wide  apart  and  hands  against 
the  wall;  the  feet  are  purplish,  with  dark,  livid  patches;  skin  looks  tense, 
swollen,  and  glazed  ;  the  soles  of  feet  are  blistered  ;  both  feet  are  of  icy  coldneSs, 
and  are  kept  somewhat  rigid,  but  there  is  no  genuine  contracture  ;  Ijoth  knee- 
jerks  are  extremely  sluggish.  He  takes  a  wide  basis  of  support,  straddles  much, 
and  tends  to  roll  over  on  his  head  ;  tongue  is  protruded  in  a  slovenly  fashion,  first 
on  one  side,  then  on  the  other  ;  no  labial  tremor ;  voice  loud,  boisterous  and 
harsh  ;  hands  tremble  much  with  voluntary  efforts  ;  much  twitching  and  corruga- 
tion of  brow-muscles,  and  also  of  facial  muscles  generally ;  fi-equent  sudden 
startings  of  the  body  and  limbs.  He  is  still  incoherent  and  jocular;  habits 
degraded  ;  sensibility  is  not  much  impaired  in  the  limbs. 

Dec.  10. — Again  improved;  walks,  however,  insecurely;  knee-jerk  almost  abolished 
in  right  leg,  but  somewhat  brisk  on  left  side.  He  is  garrulous,  incoherent,  jocular, 
and  mischievous. 

In  this  connection,  therefore,  the  further  evolution  of  symptoms 
has  a  topographical  significance,  and  the  morbid  lesions  have  their  site 
indicated  in  the  motor-areas  of  the  cortex,  or  the  ganglionic  masses  at 
the  base.  The  cortical  motor-areas  are  especially  indicated  as  those 
earliest  implicated ;  upon  them  seems  to  fall  the  full  weight  of  the 
toxic  agency ;  these,  the  fountain-heads  of  volitional  activities,  have 
their  energies  impaired  and  vitiated.  It  is  no  disorder  of  co-ordination 
which  we  witness  here ;  it  is  that  of  a  g'enuine  paFesiS — an  absolute 
impairment  of  energy  in  the  highest  motor  mechanisms.  Far  different 
is  it  with  an  allied  affection  of  the  nervous  centres,  also  associated  with 
psychical  disturbances — general  paralysis.  It  is  characteristic  of  this 
latter  disease  that  the  implication  results  in  disorders  of  cO-OPdination ; 
in  it,  also,  the  moSt  Special  muscular  adjustments  are  disturbed,  but  in 
the  direction  of  their  co-ordinate  action,  and  not  so  notably  in  an  actual 
dhninution  of  motor  energy.  In  another  affection  also,  a  system-disease 
of  the  spinal  cord,  apt  to  be  associated  with  special  mental  symptoms 
(that  of  locomotor  ataxy),  we  also  find  the  muscular  power  unimpaired, 
but  the  associated  groupings  of  muscular  movements  vitiated. 

Motor  impotence,  therefore,  not  inco-ordination  or  ataxy,  is 

the  distinctive  feature  of  alcoholism  of  the  motor  sphere  of  the  cere- 
brum. How  does  this  motor  enfeeblement  betray  itself?  The  earliest 
indication!  is  usually  a  notable  degree  of  fine  muscular  tremor,  impli- 
cating in  the  first  place  the  fingers  and  hand,  and  gradually  spreading 
up  the  arm ;  in  the  next  place  involving  the  tongue,  lips,  and  articu- 
latory  muscles  generally ;  and  lastly,  extending  to  the  foot  and  leg. 
This  tremor  is  always  more  marked  in  the  morning,  and  may  be 
dissipated  by  a  glass  of  spirits ;  if  at  first  not  obvious,  it  may  often  be 
brought  out^by  prolonged  extension  of  the  arm ;  any  slight  voluntary 
exertion  tending  to  establish  it,  it  appears  as  a  rapid  and  fine  oscilla- 
tion of  the  fingers  and  hand.     A  still  more  important  sign,  however,  is 


326  ^ALCOHOLIC    INSANITY. 

that  of  muscular  timtching,  varying  from  the  twanging  of  individual 
fibres  to  a  somewhat  coarse  fascicular  contraction,  implicating  those 
muscles  which  co-operate  in  the  most  special  forms  of  movement — the 
lips  and  tongue  (as  in  speech),  the  corrugatores  and  orbicularis  palpe- 
brarum (as  in  emotional  expression).  Occasionally,  the  spasmodic 
action  of  the  orbicularis  palpebrarum  is  such  as  to  distort  the  features 
into  sudden  and  changeable  grimaces,  or  the  whole  muscular  apparatus 
of  lips  and  mouth  is  shaken  with  a  universal  tremor ;  or  the  head  and 
neck  may  be  violently  jerked  to  one  side  by  the  convulsive  action  of 
the  scaleni  and  sterno-masioidei,  as  in  the  patient,  J.  J.,  who  attributed 
the  movement  to  electric  currents  applied  by  the  medical  officers. 
When  the  facial  muscles  are  widely  affected,  the  subject  often  presents 
a  highly  characteristic  state.  Immobile  fixation  of  the  facial  muscles 
gives  a  stolid  aspect  to  the  expression,  whilst  silent  and  undisturbed  ; 
but  when  roused  to  converse,  the  efibrt  at  times  causes  such  universal 
tremor  as  is  seen  on  the  eve  of  a  flood  of  violent,  incontrollable 
weeping,  or  upon  the  onset  of  an  explosion  of  passion.  The  tremulous 
convulsive  wave  which  passes  over  the  face  can  be  often  aroused 
by  pressing  questions  upon  the  patient,  or  any  slight  confusion. 
Convulsive  jerking  of  the  tongue  may  be  complained  of;  thus  the 
patient  J.  C,  when  recovering,  especially  alluded  to  the  fact  that  he 
no  longer  found  his  tongue  "jumping  in  his  mouth."  The  patient 
will  often  recognise  this  muscular  failure,  and  when  speaking  will  put 
up  his  hand  to  conceal  the  mouth  or  steady  its  movements.  Pari 
passu  with  this  muscular  twitching,  paresis  of  the  tongue  proceeds, 
its  movements  become  generally  impeded,  and  speech  is  thick  and 
blurred.  The  stolidity  of  aspect  is  due  to  defective  tone  ;  and  when 
voluntary  innervation  occurs,  then  only  is  such  stolidity  dissipated  ; 
yet  irregular  asymmetpic  fUPPO wing's  of  the  muscles  of  the  brow 
are  often  oVjvious,  due  to  irregular  contractions  or  paralysis  of  the 
antagonistic  groups. 

Reaction-Time  in  Alcoholic  Insaniti'. 


G.  H.,  .  .  Much  muscular  tremor,     ..... 

J.  M.,  .  .  Chronic  alcoholism,  delusions  of  persecution, 

H.  W.,  .  Chronic  alcoholism,  delusional  insanity,  violent, 

H.  G.,  .  .  Dangerous,  homicidal,  delusions  of  persecution, 

W.  W.,  .  Chronic  alcoholism,  dement<-d,  morbus  Brifjhtii, 

J.  C,    .  .  Slight  mania,  liallucinations,  suspicious,  tremulous, 

E.  L.,   .  .  Chronic  alcoholism,  haHucinatioJis  and  delusio?is 
of  suspicion,        ...... 

R.  B.,  .  .  Chronic  alcoholism,  hypochondriasis,  suspicion, 


Acoustic 

Stimulus. 

Sec. 

Optic 

Stimulus. 

Sec. 

•14 

•23 

•15 

•21 

•17 

•26 

■18 

•21 

•18 

•25 

,      -18 

•25 

•19 

•25 

•19 

•26 

MOTOR    ENFEEBLEMENT — REACTION-TIME. 


327 


Reaction-Time  in  Alcoholic  Insanity— Cowimued. 


J.  Ji., 


G.  A.,  . 


J. 

M.,  . 

G 

M.,  . 

W 

.  S.,  . 

P. 

T.,   . 

J. 

J-*.,  . 

M 

.  H.  L 

J. 

G.,   . 

J. 

J3.,    . 

J. 

F.,    . 

T. 

C,   . 

Acoustic 
Stimulus. 


•20 


Optic 
Stimulus. 


•26 


Chronic  alcoholism,  hallucinations,  delusions  of 
persecution,         ...... 

Chronic    alcoholism,    delusions    of  persecution, 
violent,       ...... 

Extreme  depression,  suicidal,  suspicious,    . 
Mania  a  potu,  excited,  voluble, . 
Tabetic,  deluded,  treacherous,  homicidal,  . 
Chronic  alcoholism,,  hallucinations,  suspicious, 
Delusions    of  persecution,    grim,    treacherous, 
homicidal, ...... 

Apathetic,  slight  mental  enfeeblement,  amnesic. 
Chronic  alcoholism,  delusions  of  persecution. 
Chronic  alcoholism,  maniacal,  ivild,  boisterous. 
Chronic  alcoholism,  notable  amnesia, 
Chronic  alcoholism,  demented,  degraded,    . 


The  above  may  be  usefully  compared  with  the  results  obtained  from 
subjects  of  ordinary  forms  of  depression  and  exaltation. 


•20 

•26 

21 

•24 

21 

•25 

21 

•25 

•21 

(Blind) 

•22 

•2.3 

22 

•25 

22 

•27 

22 

•29 

•22 

•29 

•30 

» 

Reaction-Time  in  Depression  and  Exaltation. 


J.  H.  B., 

Simple  melancholia,  . 

C.  K.,  . 

Hypochondriacal  melancholia. 

C.  P.,   . 

.     Delusional                      „ 

s.  s.,   . 

Chronic 

E.  H.,  . 

Simple 

E.  D.,  . 

>  J 

J.  M.,  . 

Hypochondriacal 

J.  H.,  . 

,, 

J.  E.,    . 

Simple 

G.  H.,  . 

,, 

G.  P.,  . 

Chronic 

J.  W.,  . 

Hypochondriacal 

T.  E.,  . 

Chronic 

R.  W., 

Simple 

S.  W.,  .     . 

Climacteric 

W.  T., . 

Acute  mania,    . 

W.  W., 

)>         >> 

W.  H., 

Simple  subacute  mania. 

M.  R., . 

j>                 >) 

W.  M'C, 

Acute  mania,    . 

Acoustic 

Stimulus. 

Sec. 

Optic 

Stimulus 

Sec. 

•13 

•20 

•14 

•24 

•18 

•21 

•18 

•18 

•18 

•18 

•21 

•28 

•21 

•20 

•21 

•27 

•13 

•27 

•19 

•24 

•22 

•27 

•23 

•23 

•26 

•27 

•29 

•30 

•29 

•29 

•17 

•24 

•17 

•24 

•18 

•23 

•19 

•25 

•22 

•22 

Increase  of  the  specific  resistance  in  the  motor  nerve- trunks  may 
possibly  explain  the  tremor,  but  that  it  is  largely  due  to  defective 
innervation  of  nerve-centres  discharging  along  those  tracts  is  highly 


328  ALCOHOLIC    INSANITY. 

probable,  both  elements  taking  part  in  the  morbid  state ;  for,  even  if 
the  former  (that  is,  the  specific  resistance)  he  not  directly  augmented,  it 
is  relativeli/  so  increased  by  a  fall  in  the  energy  of  the  centre.  A 
continuous  contraction  is  thereby  rendered  impossible  from  want  of  a 
sufficiently  rajiid  discharge  from  the  nerve-centre;  such  nerve-shocks  are 
not  given  off  sufficiently  quick  ;  and  the  resulting  contractions  do  not 
fuse  into  one  tonic  contraction,  as  in  a  healthy  physiological  state. 
That  a  pathological  change  occurs  in  the  motor  nerve-trunks  is  also 
indicated  by  the  occurrence  of  muscular  twitchings,  indicative  of  an 
irritative  process  of  the  nerve-fibres  affecting  the  motor  end-plates,  and 
terminating  later  on  in  a  more  or  less  pronounced  paresis  of  certain 
muscular  groups,  which  are  then  overbalanced  by  their  antagonistic 
series,  producing  the  asymmetric  muscular  modelling  of  the  face  already 
alluded  to. 

Muscular  spasms  and  cramps  are  another  frequent  accompaniment 
of  chronic  alcoholism  of  the  nerve-centres.  They  chiefly  occur  at 
night,  and  especially  when  waking  from  sleep.  Their  severity  is 
great;  the  muscles  of  the  upper  and  lower  extremities  chiefly  suffer, 
and  the  resultant  pain  and  contraction  is  often  attributed  by  the 
subjects  to  the  influence  of  their  unseen  foes.  They  speak  of  their 
wrists  being  wrenched  round,  their  arms  twisted  and  deformed,  and 
their  legs  subjected  to  frightful  torture,  and  they  complain  of  aching 
pains  and  feelings  of  fatigue  in  the  limbs  for  prolonged  periods.  Such 
cramps  occur  late  into  the  history  of  the  alcoholic,  and  are  often  at 
night  associated  with  frightful  dreams,  when  phantasms  are  often 
woven  into  the  delusional  web  constituting  his  mental  life. 

The  oculo-motor  apparatus  is  by  no  means  so  frequently  involved 
as  in  the  allied  affection — general  paralysis.  The  pupils  are  often 
dilated  and  sluggish  in  reaction,  they  are  seldom  unequal  in  size,  and 
the  most  advanced  cases  show  often  no  impairment  in  the  reflex 
adjustments  apart  from  indications  of  a  localised  sclerosis. 

Nystagmus  (as  the  result  of  cerebro-spinal  sclerosis)  is  of  somewhat 
frequent  occurrence  in  chronic  alcoholics.  Thus,  in  J.  IF.,  continuous 
movement  of  the  eyeballs  occurred  in  a  horizontal  plane. 

Epileptiform  Attacks. — A  highly  characteristic  group  of  symptoms 
inaugurates  a  later  stage  of  alcoholism.  The  patient  is  suddenly 
seized  with  faintness,  tremblings  in  the  limbs,  extreme  pallor,  and 
breathlessness ;  vomiting  may  supervene ;  and  then  slight  twitching 
may  or  may  not  extend  to  a  convulsive  starting  of  a  whole  limb  (or 
one  side  of  the  body),  or  become  generally  spread  over  all  the  limbs, 
but  rarely   with   complete   loss  of  consciousness.      Upon  recovery   a 

monopleg"ia  or  hemipleg'ia  may  be  found  to  exist,  and  aphasic 

conditions  are  by  no  means  infrequent.     At  times  symptoms  ominous 


CONVULSIVE    ATTACKS CASE    OP    T.    P.  329 

of  such  attacks  present  themselves,  but  do  not  issue  in  convulsion 
or  paralysis ;  a  slight  dizziness  or  actual  vertigo,  accompanied  by  syn- 
copal attacks,  or  a  mere  tendency  to  faint,  may  be  noted ;  or  there 
may  be  pallor  of  face,  associated  with  a  cold  perspiration,  while  the 
patient  sinks  exhausted  into  a  chair,  but  may  rapidly  recover,  com- 
plaining only  of  numbness  or  tingling  in  arm  or  leg.  The  sudden 
onset  of  unilateral  twitching  in  the  face,  followed  by  slight  paralysis  of 
that  side,  is  of  frequent  occurrence  in  such  cases  ;  and  slight  "  strokes  " 
of  one  side  of  the  face,  or  of  a  limb  (that  is,  slight  in  degree  of  impli- 
cation), and  of  very  transient  duration,  is  a  prevailing  symptom  which 
recurs  over  and  over  again  in  this  aifection. 

T.  P.,  aged  sixty-two,  widower,  a  shoemaker  by  trade,  a  man  of  moderate 
height,  well-nourished,  but  bald  at  vertex  with  scanty  grey  hairs  around  the 
head ;  the  right  pupil  somewhat  the  larger  of  the  two,  both  active  in  their  re- 
action ;  the  tongue  protruded  straight,  is  tremulous,  superficial  arteries  hard, 
corded,  tortuous,  incompressible.  There  is  no  history  of  inherited  insanity.  For 
many  years  he  has  been  a  drunken,  worthless  character,  but  has  not  before 
suffered  from  insanity;  for  twelve  years  past  his  drinking  habits  had  become 
most  excessive,  and  it  was  apparent  to  all  that  his  memory  was  implicated,  his 
mental  powers  were  becoming  enfeebled,  and  his  behaviour  childish.  Three 
months  prior  to  his  admission  at  the  asylum,  he  was  taken  to  the  Union  Work- 
house, where  he  developed  more  active  symptoms,  was  restless  at  night,  developed 
vague  fears,  could  not  sleep,  "because  some  one  might  kill  him."  Aural  hallu- 
cinations became  now  apparent,  and  a  voice  distinctly  ordered  him  to  take  his 
own  life.  Then  it  became  evident  that  he  was  the  subject  of  convulsive  seizures; 
he  denied  ever  having  had  a  paralytic  stroke.  He  was  attentive  in  his  habits,  not 
destructive,  and  not  violent. 

The  morning  succeeding  his  admission  he  was  restless,  emotional,  bursting  into 
tears  whenever  mterrogated ;  there  was  profound  dementia.  He  was  quite 
oblivious  to  his  recent  history,  and  did  not  know  whether  he  had  been  days, 
months,  or  years  at  the  asylum ;  in  fact,  all  his  notions  respecting  time  were 
faulty.  His  memory  failed  to  retain  even  for  a  few  moments  what  he  was  told. 
His  articulation  was  thick,  blurred,  and  at  times  so  indistinct  as  to  be  wholly 
unLutelligible.     In  general  appearance  he  was  decidedly  sottish. 

Shortly  after  admission,  he  had  one  slight  epileptoid  seizure  ;  and,  with  this 
exception,  he  had  no  further  convulsive  seizures  for  some  months,  when  a  succes- 
sion of  eight  fits  occurred  one  morning,  leaving  him  exceedingly  torpid  and  sub- 
conscious. From  this  state  he  rallied  sufficiently  to  go  about  again  ;  but  was 
weak  and  tottering  in  his  gait,  and  frequently  staggered  backwards.  His  dementia 
was  more  pronounced — he  was  very  quarrelsome.  One  morning,  shortly  after 
this,  he  was  seized  with  severe  convulsions,  occurring  almost  without  intermission 
in  the  right  limbs,  side  of  face  and  body,  and  slightly  in  the  left  leg.  Thirty 
grains  of  chloral,  given  per  rectum  twice  in  half-an-hour,  caused  arrest  of  the 
convulsions.  Next  morning  he  was  aphasic,  but  no  paralysis  persisted  in  the 
limbs  recently  affected.  During  the  succeeding  three  or  four  months,  he  had 
frequent  recurrence  of  such  convulsive  seizures,  with  precisely  the  same  motor 
distribution  as  in  the  former  attack,  and  chloral  in  all  cases  rapidlj'  arrested  the 
convulsions. 


330  ALCOHOLIC    INSANITY. 

Two  years  after  admission,  it  is  noted — "  Fits  occur  at  rather  short  intervals  ; 
patient  is  much  more  demented  and  feeble,  reels  and  falls  backwards  if  standing 
whilst  in  conversation,  and  at  other  times  when  simple  forward  movements  are 
interfered  with  ;  his  movements  are  stiff  aud  awkward  ;  usual  attitude,  with  the 
arms  crossed  firmly  on  front  of  chest,  his  head  bowed  forwards.  He  is  gloomy, 
irascible,  and  rarely  smiles  ;  curses,  and  attempts  to  strike  when  irritated.  Habits 
usually  clean.     Acne  rosacea  very  marked  over  nose  and  cheek." 

Eight  months  later — "  Articulation  is  now  an  unintelligible,  low-pitched  mumble, 
except  when  angry  ;  he  then  uses  curses  which  are  plain.  Pupils  equal,  of  normal 
size ;  no  tremor  of  tongue ;  he  drivels  much ;  is  very  tottering  and  feeble ;  gradually 
emaciating."  A  few  months  later,  he  sank  in  a  condition  of  stupor,  following 
convulsive  seizures  of  the  same  nature  as  those  already  described. 

(Sectio  Cadav.)  Skull-cap  symmetrical,  bones  thicker  than  normal  aud  very  pale ; 
slight  adhesions  of  the  dura  mater.  In  frouto-parietal  lobes  of  brain  there  is  con- 
siderable wasting,  most  marked  in  the  left  hemisphere,  and  peculiarly  so  in  the 
ascending  parietal  convolution  and  the  boundaines  of  the  Sylvian  fissure  ;  both 
hemispheres,  however,  have  suffered  much  from  this  atrophic  process.  The  great 
vessels  at  the  base  are  all  extremely  atheromatous.  The  brain  is  pale  as  a  whole, 
and  its  consistence  somewhat  reduced  ;  the  membranes  are  thickened,  cedematous, 
and  readily  strip  ;  the  section  of  the  brain  shows  much  pallor  of  the  cortex,  which 
is  notably  diminished  in  depth  in  the  regions  already  referred  to  as  wasted  ;  the 
white  substance  is  firmer  than  usual,  but  evidently  diminished  in  bulk,  and 
encroached  upon  by  greatly  dilated  lateral  ventricles,  which  contain  9  ounces  of 
fluid.  A  very  small  patch  of  brown  induration  was  found,  implicating  the  pos- 
terior portion  of  the  right  corpus  striatum.  The  ganglia  elsewhere  and  the 
cerebellum  presented  nothing  abnormal.      Whole  brain  weighs  1,234  grammes. 


Right  hemisphere. 

.     516  grms. 

Left  hemisphere, 

.     515  grms. 

Right  frontal  lobe. 

.     235     „ 

Left  frontal  lobe. 

.     204     „ 

Cerebellum, 

•     127     „ 

Pons  and  medulla. 

.       23     „ 

Heart  and  lungs  present  nothing  unusual  beyond  hypostatic  engorgement  of  the 
latter.  Liver  weighs  1,366  grms.  ;  is  adherent  to  diaphragm  by  tough  adhesions 
of  its  capsule  ;  its  substance  is  dark-pigmented,  and  very  firm  ;  in  the  right  lobe 
near  its  upper  surface  is  a  large  cyst  with  a  distinct,  white,  tough  capsule,  and 
containing  clear  fluid.  Spleen,  85  grms. ;  also  firmly  adherent  to  stomach  ;  its 
substance  congested,  soft  and  dark.  Right  kidney,  163  grms.;  capsule  thin,  strips 
from  a  smooth,  pale  surface,  revealing  numerous  shallow  scars  ;  both  cortical  and 
medullary  portions  are  much  reduced — the  pelvis  dilated  and  full  of  fat ;  the  organ 
generally  is  pale  and  unduly  fibrous.  Left  kidney,  130  grms.  Structure  reduced 
to  a  narrow  strip  \  inch  in  diameter  by  a  huge  hydro-uephrosis — the  pelvis  being 
enormously  dilated. 

It  must  be  obvious  from  the  foregoing  considerations  that  any 
division  of  chronic  alcoholism  into  separate  clinical  groups  must  be  a 
purely  arbitrary  measure,  justified  only  on  the  grounds  of  convenience 
in  clinical  teaching,  and  in  the  study  of  the  wide-spread  meanderings 
of  the  diseased  process;  that,  with  greater  or  less  psychical  disturbance, 
either  sensorial  or  motorial  anomalies  may  preponderate  ;  and  that  the 


CONVULSIVE    ATTACKS — CASE    OF    J.    C.  331 

most  notable  fact  is  the  tendency  to  a  serious  degenerative  process, 
first  (but  not  necessarily  so)  implicating  sensory  areas,  and  then  trans- 
ferred to  motor  realms  of  the  brain,  implicating  in  its  course  the 
moral  and  intellectual  faculties.  Huss  divided  his  cases  of  chronic 
alcoholism  into  six  forms  : — 

1.  The  Prodromal.  4.   Hyperaasthetic. 

2.  Paralytic  or  Paretic.  5.   The  Convulsive. 

3.  Anaesthetic.  6.  Epileptic. 

Magnan,  whilst  justly  criticising  this  division  as  not  a  genuine 
clinical  grouping,  specially  calls  attention  to  one  form — the  hemian- 
sesthetic  type — which,  from  clinical  and  pathological  considerations, 
he  deems  worthy  of  this  dignity. 

J.  C,  aged  sixty,  a  widower,  employed  at  his  trade  as  currier  up  to  a  week 
preceding  his  admission,  although  his  mental  enfeeblement  must  have  been  of  some 
duration,  judging  from  his  state  at  that  time.  It  would  appear  that  a  woman, 
with  whom  he  cohabited  after  his  wife's  death,  had  concealed  his  mental  ailment 
from  notice,  with  the  object  of  profiting  by  his  earnings.  A  maniacal  outburst, 
however,  rendered  him  dangerously  violent,  and  she  had  to  seek  assistance  from 
the  Union  authorities,  who  found  him  incoherent  and  wildly  excited.  He  was 
said  to  have  lived  a  temperate  life ;  to  have  had  no  convulsion,  stroke,  or  cranial 
injury ;  and  to  have  exhibited  failure  of  memory  only  quite  recently.  All  these 
statements,  however,  were  received  with  reserve,  owing  to  the  relationship  exist- 
ing and  alluded  to  above.  The  maniacal  attack  may  possibly  have  been  the 
sequel  to  a  convulsive  seizure  unperceived;  be  this  as  it  may,  the  Relieving  Officer 
found  him  noisy,  incessantly  talking  in  an  incoherent  strain,  violent  to  all  around, 
and  kicking  his  furniture  downstairs,  declaring  he  was  moving  his  home.  He  had 
slept  but  little  for  nearly  a  week. 

He  was  a  short,  thick-set  individual^  5  feet  3  inches  high,  and  weighing  over 
10  stones;  of  florid  complexion,  with  dilated  malar  capillaries;  bald  at  vertex,  with 
grey  tonsure.  His  locomotor  system  appeared  unafi^ected,  and  his  grasping  power 
was  good;  his  speech  betrayed  no  defect.  His  body  generally  was  obese,  but 
there  was  no  distinct  evidence  of  cardiac  degeneration  upon  auscultation,  nor 
were  the  superficial  vessels  notably  hard  or  corded.  His  mental  state  was 
that  of  maniacal  excitement ;  he  was  garrulous,  silly  in  his  utterances,  and 
always  irrelevant.  His  memory  for  remote  events  was  good,  but  for  recent  events 
it  was  wholly  at  fault ;  he  was  utterly  inappreciative  of  the  nature  of  his  surround- 
ings and  present  condition;  attention  could  only  be  commanded  wibh  extreme 
difficulty,  owing  to  his  rambling  off  into  disconnected  utterances.  His  mood, 
although  variable,  was  usually  cheerful  and  lively ;  no  delusion  was  expressed,  and 
no  hallucinations  were  apparent. 

For  a  week  following  his  admission,  he  was  given  four-drachm  doses  of  succus 
conii  three  times  daily ;  the  physiological  effect  of  the  drug  was  freely  induced, 
but  his  excitement  did  not  succumb  to  its  influence;  and  as  he  was  weak  and 
somewhat  exhausted,  the  drug  was  discontinued.  The  excitement  persisted  for 
two  months,  during  which  he  lost  weight  and  looked  very  ill ;  but,  upon  its  abate- 
ment about  this  time,  he  again  began  to  gain  in  weight,  betraying,  however,  a  very 


332  ALCOHOLIC    INSANITY. 

notable  degree  of  dementia.  No  further  maniacal  outburst  occurred,  and  he  was 
relegated  to  the  class  of  indolent,  harmless,  and  helpless  jiatients.  A  large 
haematoma  auris  now  developed — it  was  believed  as  the  result  of  a  fall  on  the  floor. 
Eighteen  months  after  admission,  lie  appears  to  have  had  a  paralytic  seizure  affect- 
ing both  limbs  on  the  left  side,  in  which  common  sensation  was  somewhat  blunted 
and  the  siiperticial  reflexes  were  impaired.  He  remained  torpid  and  heavy  for 
a  few  days,  and  was  then  allowed  to  get  up ;  he  was  very  feeble  in  limb,  and  the 
left  leg  dragged  slightly  during  progression.  The  ensuing  two  months  were 
marked  by  rapid  advance  of  physical  and  mental  prostration,  due  to  progressive 
atrophy  of  the  brain ;  his  mental  faculties  were  now  almost  wholly  abolished  ;  nor 
could  he  stand  up,  although  he  was  able  to  move  his  hands  and  arms  freely,  and 
with  some  degree  of  force ;  if  placed  in  the  erect  position,  unless  supported,  he 
would  double  up  at  once.  The  tongue  is  protruded  to  the  left,  and  is  tremulous. 
At  tliis  period  he  was  subject  to  threatening  attacks  of  passive  congestion  of  the 
lungs,  due  to  failing  cardiac  energy. 

Two  years  after  admission,  he  was  completely  bedridden,  quite  helpless,  and 
incapable  of  changing  his  position;  a  bedsore  formed  over  each  great  trochanter; 
his  lungs  were  congested  at  their  bases,  but  his  pulse  was  fair,  and  his  appetite 
good,  much  fluid  nourishment  being  taken ;  he  was  utterly  fatuous  in  aspect,  and 
mindless.  Cardiac  energy,  however,  upon  which  so  much  depends  in  the  survival 
of  these  chronic  invalids,  at  last  became  rapidly  exhausted;  the  lungs  became 
greatly  engorged,  and  he  died  comatose  two  years  and  four  months  after  admission 
to  the  asylum. 

The  pod-mortem  examination  revealed  a  thickened,  gelatinous,  and  opaque  aspect 
of  the  soft  membranes  over  the  anterior  half  of  both  hemispheres.  They  were 
removed  witli  the  greatest  ease,  presenting  no  morbid  adhesion  at  any  site,  and  were 
buoyed  up  by  a  considerable  amount  of  serous  fluid  efi"used  between  them  and  the 
brain-surface.  Very  considerable  atrophy  w^as  noted  in  the  frontal,  anterior  part 
of  parietal,  and  temporo  sphenoidal  lobes,  their  convolutions  being  notably  wasted 
and  their  sulci  gaping.  The  large  vessels  at  the  base  were  atheromatous — and  the 
nutrient  vessels  of  the  basal  ganglia  were  notably  coarse.  The  grey  cortex  was 
much  diminished  in  depth;  the  white  substance  appeared  normal;  no  focus  of 
softening,  no  undue  reduction  in  consistence,  and  no  clot,  recent  or  old,  were 
noted.  The  cerebellum,  pons,  and  medulla  appeared  healthy.  Xine  ounces  of 
compensatory  fluid  escaped. 


Right  hemisphere, 

.     456  grms. 

Left  hemisphere, 

.     450  grms. 

Right  frontal  lobe. 

.     185      „ 

Left  frontal  lobe. 

•     173      „ 

Cerebellum, 

.     130      „ 

Pons  and  medulla. 

•       19      „ 

^Vhole  brain  = 

=  1067  grammes. 

Heart,  353  grms.  ;  valves  competent  to  the  water-test;  atheromatous  deposits  at 
base  of  aorta;  muscular  walls  unusually  thinned,  softened,  and  fatty.  There  was 
much  dilatation  of  all  its  cavities.  The  lungs  presented  much  congestion  of  their 
bases. 

Liver,  1233  grms. ;  pale  externally,  and  upon  section  fatty,  and  very  friable. 

Spleen,  133  grms. ;  dark  and  softened. 

Right  kidney,  148  grms.  ;  capsule  stripped  with  ease  from  a  pale,  fatty  surface; 
the  cortical  layer  was  considerably  thinned,  and  a  large  cyst  was  present. 

Left  kidney,  145  grms. ;  condition  in  every  way  similar  to  its  fellow. 


TYPES   OF   ALCOHOLIC    INSANITY.  333 

It  has  already  been  shown  by  our  remarks  on  the  evolution  of  the 
psychical  symptoms,  that  the  invasion  of  the  cerebrum  by  this  agency 
often  follows  a  very  definite  course ;  and  it  is  only  in  the  later  stages, 
when  the  wide-spread  sclerosic  changes  in  the  nerve  centres  and  the 
degenerative  vascular  lesion  are  most  apparent,  that  we  may  get  that 
protean  aspect  from  a  multiplicity  and  complexity  of  symptoms,  which 
led  Magnan  to  state  that  "  we  do  not  know,  in  fact,  what  symptom 
there  is  which  might  not  be  associated  with  chronic  alcoholism  under 
one  or  other  of  these  conditions."  *  Such  multiform  symptomatology, 
however,  does  not  pertain  to  the  earlier  stage  of  the  affection,  and  we 
then  cannot  fail  to  note  the  tendency  to  a  restriction  of  the  more 
2yronouncecl  symptoms  to  one  or  the  other  sphere  of  cerebration. 
Thus  it  is  often  noted  that  the  symptoms  are  almost  exclusively 
sensorial,  hallucinations  being  a  most  pronounced  feature,  whilst 
little  or  no  genuine  intellectual  disturbance  is  recognised  or  but  trivial 
motor  ailment ;  other  cases  present  themselves  where  the  ailment, 
from  the  outset,  has  been  a  failure  in  the  sphere  of  the  intellect,  with 
little  or  no  sensorial  or  motorial  implication ;  and  lastly,  there  are 
those  cases  where  the  full  action  of  alcohol  appears  to  have  been  ex- 
pended upon  the  motor  sphere  of  the  brain  after  a  very  short  term 
of  sensorial  disorder.  Yet,  the  symptoms  of  implication  of  special 
cerebral  territories  too  often  dovetail  and  overlap  for  any  trustworthy 
clinical  classification  to  be  adopted ;  and  still  more  frequently,  if  the 
history  be  one  of  progressive  invasion  of  one  territory  after  another. 
The  more  characteristic  forms,  however,  under  which  cerebral  alcohol- 
ism presents  itself  to  our  notice  in  asylums  for  the  insane,  are  the 
following : — 

1.  Purely    sensorial    type — {a)    common    sensibility;    (h)   visceral; 
(c)  special. 

2.  Primary  amnesic  forms. 

3.  Premature  senility,  especially  implicating  motor  areas  of  cortex. 

4.  Delusional   forms    with   vascular    lesions   in    basal   ganglia   and 
medullated  tracts  of  the  cerebrum. 

5.  Motorial  types. 

*  Op.  ciL,  p.  158. 


334  TDK    INSANITY    OF    PUBERTY    AND    ADOLESCENCE. 


INSANITY  AT  THE  PERIODS  OF  PUBERTY  AND 
ADOLESCENCE. 

Contents. — Evolution  of  Puberty  and  Adolescence— Pubescence  as  Distinguished 
from  Adolescence — Antagonism  of  Growth  and  Development— Excessive 
Metabolism  of  Infancy — Acquisitiveness  and  Mimetic  Characters  of  Childhood 
—Initiative  Tendencies  of  Adolescence— Pubescent  Insanity  in  the  Female — 
Delusions  and  Hallucinations — Relapses  at  Menstrual  Periods — Hysteric  Type 
of  Mania— Stupor  Coincident  with  Menstrual  Derangement — Case  of  F.  W. — 
The  Blood  in  Stuporose  States— Case  of  M.  A.  H.— Etiology— Ancestral 
Influence— Periods  of  Susceptibility— Statistics  of  Hereditary  Factors— Ovarian 
Derangements  and  Pubescent  Insanity  (A.  H.) — Amenorrhceal  and  Anaemic 
States— Influence  of  the  Environmental  Factors— Percentage  of  Hjemoglobin  in 
Cases  of  Stupor — Pubescent  Insanity  in  the  Male— Sexual  Divergence- 
Symptoms  of  Pubescent  Insanity — Modified  Forms  (J.  M.) — Masttirbatic  and 
Uncomplicated  Form  of  Pubescent  Insanity — Etiology — The  Moral  Imbecile. 

The  Physiolog'ical  and  Psycholog"icaI  Evolution  of  Puberty 

and  Adolescence. — Of  all  phases  of  human  life,  physiology  deals 
with  none  more  instructive  than  that  of  its  critical  periods. 
During  the  first  and  second  dentition  necessitated  by  altered  condi- 
tions of  life ;  during  puberty  and  adolescence,  when  the  procreative 
faculties  are  being  unfolded ;  during  the  decay  and  obsolescence  of 
these  faculties  at  the  menopause  and  grand  climacteric  ;  and  lastly, 
during  the  final  retrogression  of  senility — the  physiological  changes  are 
fraught  with  profound  interest,  and  in  no  less  a  degree  do  serious 
departures  from  normal  functional  activities  prove  suggestive  to  the 
pathological  enquirer.  The  period  of  puberty,  if  we  neglect  those 
variations  due  to  climatic  and  social  influences,  is  usually  fixed 
between  the  ages  of  thirteen  and  fifteen  for  females,  and  of  fourteen 
and  sixteen  for  males.  It  is  emphasised  by  certain  well-marked 
external  signs,  such  as  the  prominence  and  elongation  of  the  larynx, 
and  lengthening  of  the  vocal  cords  in  the  male,  with  a  corresponding 
lowering  of  the  voice  an  octave  or  more  ;  an  increased  compass  of 
voice  in  the  female ;  the  appearance  of  hair  on  the  pubes,  in  the 
axilla,  and  on  the  face  in  the  male ;  the  widening  of  the  hips  in  the 
female,  and  the  greater  vascularity  of  the  external  genitalia;  an 
enlargement  and  greater  activity  of  the  sebaceous  glands.  These 
superficial  evidences  accompany  the  development  of  the  internal 
genital  organs,  the  maturation  of  the  Graafian  follicles,  and  the 
menstrual  flux ;  whilst  the  galactophorus  ducts  of  the  mammae  pro- 
liferate, and  true  acini  appear. 

The  genital  organs  are  usually  mature  at  this  epoch,  so  far  as  their  structure 
and  functional  activity  are  concerned  ;  therefore,  we  may  regard  menstruation 
(which  is  conclusive  evidence  of  puberty)  as  significant  of  the  arrival  of  sexual 


thp:  pubescent  epoch. 


335 


maturity.  But  it  is  well-established  that  sexual  maturity — that  is,  the  capacity 
Jor  hearimj  children — need  not  necessarily  coincide  with  puberty,  for  some  girls 
are  mature  before  menstruation  has  occurred.  If  we  have  recourse  to  Dr.  White- 
head's statistics,*  we  find  that  the  larger  proportion  of  cases  of  first  menstruation 
occur  at  the  age  of  sixteen,  and  that  nearly  60  per  cent,  of  the  four  thousand  cases 
of  puberty  recorded  by  him,  occurred  between  the  ages  of  fourteen  and  sixteen 
years.     I  have  appended  to  his  Table  the  percentages  for  each  year  : — 

At  age  of  10  years,      9  first  menstruated  ;  or  a  percentage  of    0"25 

0-65 
3-40 
8-30 
15-95 
19-02 
24-17 
12-47 
9-82 
3-45 
1-77 
0-225 
0-15 
0-05 
0-025 
0-025 
0-025 

These  Tables  indicate  that  we  may  safely  exclude  all  cases  of  insanity  under  the 
age  of  thirteen  years,  as  not  coming  under  the  category  of  what  we  are  about  to 
consider,  viz.,  insanity  occurring  in  the  male  and  female  on  the  attainment  of 
sexual  maturity,  and  through  the  period  of  adolescence.  The  small  percentage  of 
3-4  who  show  themselves  sexually  mature  at  the  age  of  twelve,  may  be  safely  left 
out  of  consideration,  more  especially  since  cases  of  insanity  occurring  at  this  early 
age  and  up  to  fifteen  are  comparatively  very  uncommon.  The  term  "sexual 
maturity"  is  liable  to  mislead;  we  must  clearly  understand  by  it — procreative 
maturity,  and  nothing  more,  since  it  by  no  means  refers  to  full  sexual  divergence, 
in  which  the  whole  frame-work  of  the  body  participates,  and  in  which  the  central 
nervous  system  also  undergoes  a  profound  change. 

The  period  of  adolescence,  however,  may  be  regarded  as  extending 
from  puberty  to  the  age  of  twenty-one  in  females,  and  twenty-five 
in  males ;  and  is  characterised  by  most  profound  changes — especially 
by  the  completed  development  of  the  osseous  system  (Power  and 
Sedgwick). 

Puberty  involves  changes  of  vast  moment  to  the  subsequent  stage 
of  manhood.  Anomalous  conditions  are  but  too  frequently  established 
at  this  epoch,  which  lay  the  foundation  for  future  physical  and  mental 
disability.  Growth  is  actively  proceeding,  and  the  osseous  and 
muscular  systems  are  adding  largely  to  their  bulk,  so  as  to  vastly 


of  10  years,   9 

11   , 

,   26 

12   , 

,   136 

13   , 

,   332 

14   , 

,   638 

15   , 

,   761 

16   , 

,   967 

17   , 

,   499 

18   , 

,   393 

19   , 

,   148 

20   , 

71 

21   , 

9 

22   , 

6 

23   , 

2 

24   , 

1 

25   , 

1 

26   , 

1 

Sterility  and  Abortion,  p.  46. 


336 


INSANITY    OF    PUBERTY    AND    ADOLESCENCE. 


increase  the  force  and  range  of  their  activities ;  but,  with  this  active 
growth,  differentiation  and  subordination  of  parts  proceed  until 

maturity   is   reached,  and  adolescence    issues    in   full    seXUal   diver- 
gence.    It  is  a  well-recognised  fact  that  full  sexual  divergence  is  not, 
as   a  rule,    ensured    until   the    framework   and    its    musculature    are 
approaching  maturity  {Carpenter);  and  in  fact,  the  extreme  differen- 
tiation   requisite    for    this    divergence    of    sexual  characters   appears 
ultimately   to  demand  a  cessation  of  that  exaggerated  nutritive  activity 
which   prevails   in  the   earlier   periods    of  adolescence.*     The    estab- 
lishment of  an  equilibrium  in  the  metabolism  is  but  one  illustration 
of  the  great  law   of   "  antagonism    between    grOWth    and  develop- 
ment, which  is  intimately  connected  with  the  law  of  reproduction  " 
{G.   H.    Lewes j).      Tissue    metabolism,    therefore,  is   by  no    means    a 
constant  for  different  periods  of  life.     The  epoch  we  are  considerino- 
is  ushered  in  by  greatly  augmented  activity  of  the  nutritive  functions, 
and  affords  a  parallel  to  the  conditions  existing  in  earliest  infancy  and 
childhood. 

Thus,  an  infant  is  known  to  treble  its  weight  within  the  first  year 
of  its  life  (LanJois  and  Stirling  1) ;  and  from  Quetelet's  researches  it  is 
seen  that  the  first  three  years  (and  especially  the  first  year)  are 
periods  of  wondrously  active  growth,  the  increase  in  stature  being  as 
follows  : — 


First  year,  a  growth  of 

Second ,,  ,, 

Third    „ 

Fifth  to  sixteenth  year,     ,, 
Twenty-tifth  to  thirtieth  year. 


20  Centimetres. 
10 

7 

54         M  per  anniun. 

Full  stature  attained. 


As  Trousseau  states — the  rapidity  of  growth  during  the  first  three 
years  would,  if  not  checked,  result  in  a  gigantic  stature,  but,  "  from 
the  beginning  of  the  fourth  year,  growth  proceeds  more  slowly  up  to 
the  age  of  puberty,  when  it  takes  a  fresh  start."  §  As  at  this  infantile 
period  (when  the  metabolism  is  so  extremely  active),  every  precaution 
is  demanded  to  maintain  the  nutritive  replacement  of  such  tissue- 
change  both  in  due  quantity  and  quality,  so  also  during  puberty  and 

*  Thus  Spiegelberg  affirms  that,  "So  long  as  the  body  has  to  provide  for  its  own 
development,  and  consequently  requires  a  large  amount  of  formative  material,  it 
has  no  energy  to  spare  for  propagatbig  the  species.  Till  development  has  ceased, 
the  organs  which  serve  for  that  purpose  remain  inactive  and  small,  and  most  of 
the  important  distinctions  between  the  two  sexes  are  absent."  (Text-book  of 
3Iidwi/ery,  New  Syd.  Soc,,  vol.  i.,  p.  59.) 

t  Li/e  0/ Goethe,  p.  355.  +  Op.  cit.,  p.  528. 

§  Clinical  Medicine,  Syd.  Soc,  vol.  v.,  p.  82. 


ANTAGONISM  OF  GROWTH  AND  DEVELOPMENT.  337 

adolescence,  too  much  care  cannot  possibly  be  lavished  in  providing 
for  the  wants  of  the  system — for  it  is  at  this  epoch,  beyond  every 
other,  that  the  physical  and  mental  characteristics  of  the  man  or 
woman  are  permanently  moulded  or  stereotyped.  A  parallel  has  been 
drawn  by  Trousseau  betwixt  this  period  of  active  infantile  growth 
and  the  subsequent  stage  of  adolescence,  wherein  he  recognises 
analogies  in  morbid  states  at  these  respective  epochs — the  osteo- 
malacia of  adults  he  thus  places  parallel  to  the  rickets  of  infancy. 
Excessive  expenditure  of  nutritive  forces  occurs  with  especial  frequency 
at  the  period  of  puberty — the  lad  in  usual  parlance  is  said  to  be  "  out- 
growing his  strength ; "  he  may  add  5  or  6  inches  to  his  stature  in  a 
single  year  {Trousseau).  As  Dr.  Edward  Smith  also  states  it: — ''The 
period  of  puberty  is  associated  with  two  classes  of  evils,  viz.,  excessive 
development  of  the  cerebro-spinal  axis,  and  defective  growth  of  the 
organs  of  organic  life."  *  Such  greatly-augmented  metabolism  taxes 
to  the  utmost  the  constitutional  powers ;  the  requirements  of  the  very 
rapidly  increasing  mesodermal  tissues  are  imperative  and  urgent ; 
circulating  albumen  is  rapidly  abstracted  by  the  growing  tissues ;  so 
that,  unless  a  more  generous  diet  be  given,  whereby  such  loss  may  be 
replaced,  serious  impoverishment  must  ensue.  Functional  disturbances 
as  a  consequence  occur,  whilst  mal-assimilation  furthers  still  more  the 
vicious  progress,  and  lays  the  foundation  for  nutritional  ailments,  such 
as  tubercle,  to  which  this  epoch  is  so  prone. 

The  excito-motor  irritability  of  infancy  with  its  jerky,  spasmodic, 
ill-directed  movements,  wanting  in  object,  wanting  in  power,  co-ordina- 
tion and  skill,  pass,  in  the  growing  youth,  under  the  control  of  higher 
centres  now  evolving.  Action  is  now  directed  to  a  definite  purpose, 
and  muscular  activity  becomes,  in  one  form  or  another,  the  supreme 
pleasure  of  the  organism ;  yet,  such  activity  is  still  chiefly  tenta- 
tive, imitative,  and  wanting  in  indications  of  prescience,  and  in  the 
accomplishment  of  elaborate  or  far-reaching  results.  Enjoyment 
appears  to  be  the  purport  of  this  vigorous  and  active  stage  of  life ; 
restless  movement  seems  to  be  necessary  for  the  expenditure  of  super- 
abundant energy ;  and  mental  acquisitiveness  lays  up  its  store  of  facts 
for  future  use  and  application.     The  growing  lad  mimics  the  man. 


' '  A  wedding  or  a  festival, 
A  mourning  or  a  funeral, 

And  this  now  hath  his  heart, 
And  unto  this  he  frames  his  song ; 
Then  will  he  fit  his  tongue 


*  Cyclical  Changes,  p.  236. 


338  INSANITY    OF    PUBERTY    AND    ADOLESCENCE. 

To  dialogues  of  business,  love,  or  strife, 
But  it  will  not  be  long 
Ere  this  be  thrown  aside. 
And  with  new  joy  and  pride. 

The  little  actor  cons  another  part ; 

****** 
As  if  his  whole  vocation, 
Were  endless  imitation." —  Wordsworth. 

With  the  advent  of  puberty  and  adolescence  all  this  is  changed  ;  the 
rapid  growth  of  the  organism  is  now  accompanied  by  rapid  transforma- 
tions of  the  nervous  centres,  and  as  the  parts  chiefly  afiected  are  the 
bony  framework,  blood-vascular  tissues,  and  the  musculature,  so  should 
we  expect  a  greater  or  less  tumult  in  the  molecular  transmutations 
occurring  at  the  centric  expansions  of  the  motor  system  of  nerves; 
hence,  the  higher  co-ordinating  centres — the  psycho-motor  area — must 
undergo  important  developmental  changes.  Correlatively,  there  dawns 
upon  the  mind  the  consciousness  of  fresh  motorial  capabilities — the 
overflowing  nascent  energies  are  directed  into  new  channels  of  activity, 
rendering  new  tracts  of  cei'ebral  tissue  permeable ;  and  fresh  motor 
combinations  arise.  An  undue  estimate  of  the  subject's  capacities 
usually  exists ;  the  imitativeness  of  youth  declines  before  the  self- 

assuranee  and  originating"  tendencies  of  the  adolescent.  Then 
there  crowd  in  upon  the  sensorium  the  impressions  aroused  by  the 
slowly-developing  generative  organs,  and  the  vague  indefinite  notions 
of  sexual  relationships  gradually  take  form  in  the  definite  divergence 
of  mature  age ;  life  begins  to  assume  a  reality  which  it  formerly 
wanted.  The  mental  characteristics  are  peculiarly  of  a  constructive 
kind ;  and  the  issue  may  be  favourable  or  vicious,  according  to  the 
education  and  training  then  received.  In  some,  the  emotional  element 
will  be  favoured,  and  reverie  indulged  in  to  a  vicious  extent,  may 
paralyse  more  useful  and  rational  activities.  In  others,  the  imagina- 
tive faculties  may  be  chiefly  stimulated  ;  the  love-sick  lad  will  pour 
out  his  plaint  in  verse ;  while  girls,  especially,  are  prone  at  this  period 
to  reverie  and  "castle-building."  For  the  fostering  of  such  vapid  states 
in  this  class  of  subjects,  the  sensational  novel  of  modern  days  appears 
specially  designed.  In  the  female  we  find  the  amiable  virtues  especially 
aroused,  whilst  in  the  male  the  dormant  motor  potentialities  express 
themselves  in  the  form  of  extravagant,  half-developed,  ill-digested 
plans,  overweening  self-esteem,  and  an  egOism  at  once  obtrusive 
and  objectionable. 

In  the  Female  Subject. 
Symptoms. — The  insanity  peculiar  to  this  epoch  is  essentially  an 
acute  neurosis,  not  that  the  intensity  of  the  symptoms  is  so  great, 


PUBESCENT    INSANITY    IN    THE    FEMALE,  339 

as  that  exaltation  and  excitement,  the  symptoms  of  an  acute  cereVjral 
process,  prevail.  Other  forms  of  insanity  (notably  that  incident  to 
the  early  puerperal  period)  exhibit  far  greater  intensity  of  excite- 
ment, yet  acute  mania  prevails ;  and,  although  extremely  rare,  even 
acute  delirious  mania  has  appeared.  This  predominance  of  maniacal 
states  over  states  of  depression  is  also  a  feature  in  the  insanity  of  the 
puerperal ;  but  it  is  even  more  prevalent  in  the  form  occurring  in 
adolescent  females.  Here,  however,  we  note  the  influence  of  sex  in 
modifying  the  type  of  the  nervous  process.  Maniacal  symptoms  like- 
wise predominate  over  depression  in  the  male ;  but  their  frequency 
and  intensity  are  notably  less  than  in  the  other  sex,  so  that  the  pre- 
valence of  melancholic  states  with  depressing  delusions  becomes  in 
this  sex  a  far  more  obvious  feature.  This  we  attribute  partly  to 
vicious  habits,  which  also  to  a  considerable  extent  influence  our 
prognosis.  With  this  emotional  perturbation  we  find  associated 
much  intellectual  derang-ement ;  delusions  of  a  definite  form 
betray  themselves  at  an  early  period  of  the  affection ;  and,  as  we  shall 
see  later  on,  are,  in  the  maniacal  forms,  highly  characteristic.  The 
melancholic  pei'versions  usually  embrace  ideas  of  persecution  or  im- 
pending trouble  ;  notions  which  commonly  assume  the  form  of  beliefs 
that  the  food  was  poisoned  by  relatives  or  friends.  From  a  study  of 
such  intellectual  and  sensorial  perversions,  we  find  that  delusions 
prevailed  in  one-half  the  cases  of  both  sexes  alike ;  whilst  about  one- 
fourth  of  either  sex  were  subject  to  hallucinations  of  the  special 
senses,  the  visual  and  aural  hallucination,  separately  or  combined, 
being  far  the  more  frequent.*  As  many  as  16  per  cent,  of  the  deluded 
cases  entertained  ideas  of  poisoning.  Religious  delusions  existed  in  a 
few  cases,  but  far  more  frequently  did  their  imagined  troubles  afiect 
their  social  or  domestic  well-being,  such  as  the  following: — '■'■Robbed 
of  all  her  possessions ;  her  house  in  flames ;  mother  dead  and  home 
ruined ;  has  murdered  some  one  and  is  pursued  by  policemen ;  is  to  be 
burnt  alive ;  men  concealed  in  her  toardrobe ;  fellow-patients  try  to 
murder  her."  These  were  the  delusive  concepts  of  some  typical  cases 
of  this  class.  In  most  cases  of  this  form  of  mental  derangement, 
however  acute  be  the  symptoms,  it  will  be  found  that  excitement 
abates  usually  at  an  early  period,  even  within  a  few  days  or  a  week 
of  admission  to  asylum  care.  The  removal  from  prejudicial  home 
influences,  the  regular  administration  of  good  nutritious  diet,  and  the 
ensurance  of  a  due  amount  of  sleep,  cuts  short  the  attack  very  rapidly. 
Yet  this  is  not  permanent;  one  or  more  relapses  are  almost  certain  to 

*  Or  to  be  exact — delusions  were  present  in  52  per  cent,  males,  and  49 '3  per 
cent,  females  ;  hallucinations  prevailed  in  25  per  cent,  of  either  sex. 


340  INSANITY    OF    PUBERTY    AND    ADOLESCENCE. 

occur  ere  convalescence  is  finally  established.  All  such  rapid  transi- 
tions from  mental  turmoil  to  calm  are  to  be  regarded  with  suspicion ; 
but  more  especially  here,  where  the  mental  derangement  is  itself  the 
expression  of  a  process  closely  related  to  the  cycle  of  ovario-uterine 
excitation.  At  each  monthly  period  the  menstrual  molimen  will  be 
associated  with  greater  or  less  cerebral  excitation ;  hence  at  these 
periods  relapses  are  apt  to  occur  {M.  C.  W.,  p.  209). 

When  there  is  decided  catamenial  irregularity  or  suppression,  when 
the  anaemia  of  puberty  exists,  we  may  with  confidence  anticipate 
a  relapse ;  nor  will  the  more  general  improvement  in  health  ensure 
perfect  recovery  in  the  majority  of  cases,  until  the  anaemia  is  so  far 
removed  as  to  issue  in  the  re-establishment  of  this  function.  Not  that 
the  return  of  the  menses  cures  the  insanity,  but  that  the  natural  advent 
of  this  flux  indicates  a  state  of  healthy  function  generally,  and  a 
condition  of  the  circulating  fluid  which  brings  up  the  nutrition  of  the 
cerebrum  to  its  wonted  vigour.  Dr.  Clouston  has  noted  this  tendency 
to  relapse  in  the  insanity  of  adolescence. 

"This  tendency  to  short,  sharp  attacks,  with  intermissions  of  more  perfect 
sanity  than  occurs  in  most  other  kinds  of  mental  disease,  with  relajjses  occurring 
one,  two,  three,  four,  and  five  times,  and  even  more  frequently,  before  recovery  or 
dementia  finally  takes  place,  may  be  taken  to  be  especially  characteristic  of  this 
insanity  of  adolescence."  * 

The  excitement  in  the  less  intense  forms  is  peculiarly  associated 
with  hysteric  symptoms ;  the  subjects  are,  withal,  often  shrewd,  calcu- 
lating, watchful  of  the  effect  produced  on  the  bystanders,  artful,  and 
cunning,  they  will  sham  epileptic  fits  or  other  ailments.  They  are 
often  wanton,  exhibit  much  abandon,  are  erotic  in  gesture,  conduct, 
and  speech,  and  obscenity  of  remark  is  by  no  means  infrequent.  One 
patient  at  her  home,  regarded  as  oblivious  to  all  that  her  medical  atten- 
dants were  doing  for  her,  enumerated  afterwards  every  remedy  tried, 
mentioning  the  dose  she  had  heard  the  doctor  order,  and  repeating  his 
diagnosis  which  she  had  likewise  overheard.  Others  will  show  much 
hysteric  sobbing  or  laughter,  or,  assuming  a  childish,  pettish  tone,  will 
become  querulous  or  wildly  passionate.  The  extravagant  nature  of 
the  delusion  often  stamps  this  hysteric  temperament.  Thus  such  sub- 
jects will  declare  that  they  are  mangled,  cut  into  small  pieces,  are  to  be 
boiled  alive  or  crucified,  yet  exhibit  no  corresponding  terror.  Again 
we  often  find  indecent  conduct  and  erotic  tendencies  associated  with 
conditions  of  religious  ecstasy,  and  boisterous,  unruly  demonstra- 
tiveness  alternate  with  states  of  great  stupor. 

F.  W.,  aged  twenty,  a  married  woman,  had  been  deranged  for  a  short  period 
when  seventeen  years  of  age,  but  recovered  at  home.     She  was  tall,  of  fair  com- 

*  Loc.  cil.,  p.  551. 


STUPOR    AND    COINCIDENT    MENSTRUAL    DERANGEMENT.  341 

plexion,  muscular,  but  extremely  pale  and  anaemic.  Highly  nervous  and  excitable. 
Regarded  as  of  unstable  mental  equilibrium,  a  neurotic  inheritance  was  naturally 
suspected,  but  upon  close  enquiry  no  clue  was  obtainable  to  such.  Her  former 
attack  (mania)  had  been  attributed  to  a  lover's  quarrel.  About  three  months 
before  admission  to  the  asylum,  she  had  shown  a  strangeness  of  behaviour  not 
customary  with  her ;  had  become  careless  of  her  household  duties,  indolent, 
negligent  of  her  husband's  requirements,  reticent  and  avoiding  contact  with  her 
relatives,  passing  her  mother  and  others  without  speaking  to  them.  She  then, 
without  any  expression  of  definite  delusion,  betrayed  strong  jealousy  of  her 
husband,  was  watchful  and  suspicious  of  his  movements,  passed  restless  nights, 
took  food  scantily,  her  health  becoming  more  and  more  impaired.  Sudden  out- 
bursts of  excitement  supervened  ;  she  was  violent,  and  when  thwarted,  would  try 
to  escape  by  the  window.  During  the  whole  of  this  time  she  suffered  much  from 
headache,  and  had  what  were  described  as  fainting  fits  upon  several  occasions. 
Under  medical  examination  her  condition  was  that  of  acute  mania,  a  strongly- 
marked  hysteric  element  being  associated  therewith.  She  would  roll  upon  the 
floor  and  sham  an  epileptic  fit,  talking  incessantly  much  incoherent  nonsense ;  no 
rational  reply  could  be  obtained  from  her.  Later,  she  exhibited  a  tendency  to 
intersperse  religious  phrases  and  ejaculations,  with  utterances  of  an  erotic  and 
obscene  nature ;  her  demeanour  meanwhile  varying  from  that  of  a  fixed  ecstasy 
to  conduct  betraying  strongly-marked  erotic  features,  boisterous  laughter,  or 
causeless  weeping  alternating  with  violent  passion  and  destructive  tendencies. 
The  respiratory  and  circulatory  systems  were  normal ;  but,  as  before  stated,  there 
was  extreme  anaemia,  which  accounted  for  the  persistent  amenorrhoea  from  which 
she  suffered.  Easton's  syrup  was  ordered,  and  a  full  nutritious  dietary  enforced 
when  necessary  by  compulsory  feeding.  The  maniacal  symptoms  continued  for 
three  weeks  unabated ;  then  periods  of  calm,  interrupted  by  sudden  excitement, 
passed  into  a  stage  where  nocturnal  excitement  alone  prevailed,  during  which  her 
habits  were  degraded.  She  was  utterly  regardless  of  all  decency,  and  erotic 
tendencies  were  still  pronounced.  The  patient's  health  now  steadily  improved ; 
she  put  on  flesh,  but  was  still  very  pale  and  anaemic.  There  was  now  no  excite- 
ment manifest,  her  condition  passing  into  one  of  listless  apathy  and  indifference, 
and  even  partial  stupor.  Decoction  of  aloes  with  iron  was  administered,  and 
a  full  amoimt  of  nourishment  was  secured,  her  appetite  being  satisfactory.  At 
intervals,  she  was  aroused  from  her  lethargy  and  would  engage  in  a  little  needle- 
work ;  six  months  after  admission  menstruation  supervened  for  the  first  time, 
and  a  notable  degree  of  mental  improvement  appeared  almost  coincident  there- 
with. She  became  cheerful,  affable,  and  active,  and  left  the  asylum  completely 
recovered  a  few  weeks  subsequently. 

The  tendency  to  stupOP  is  especially  marked  in  those  cases  where 
there  is  well-pronounced  menstPUal  derangement,  and  its  alter- 
nation with  hysteric  excitement  is  a  frequent  and  interesting  feature 
in  the  insanity  of  puberty.*     In  the  stage  of  stupor  complete  apathy 

*  In  such  instances  of  stupor  associated  with  menstrual  derangement,  changes  of 
undoubted  moment  occur  in  the  constitution  of  the  blood.  The  red  corpuscles  are 
seldom  diminished  in  number  to  any  notable  extent,  but  their  hajmoglobin  is  in  all 
cases  alike  reduced  in  amount.  In  some  we  find  the  corpuscular  value  below  half 
the  normal,  as  in  the  case  of  C.   \V.  (p.  351),  where  it  is  represented  at  •4.5,  or  that 


342  INSANITY   OP   PUBERTY   AND   ADOLESCENCE.     . 

prevails,  amounting  at  times  to  fatuity  ;  the  expression  is  stupid  and 
demented;  the  pupils  widely  dilated;  saliva  dribbles  from  the  mouth; 
none  of  the  wants  of  the  system  are  attended  to ;  the  hands  hang 
helplessly,  and  both  extremities  are  cold  and  livid.  The  subject  is 
usually  profoundly  ansemic,  a  haemic  bruit  may  be  heard  over  the 
aortic  valves,  or  the  bruit-de-diable  over  the  subclavian.  Such  symp- 
toms are  almost  invariably  associated  with  suppressed  menses,  and 
frequently  the  vicious  habit  of  masturbation  prevails. 

M.  A.  H.,  aged  nineteen,  single,  a  young  girl  of  delicate  physique,  very  thin 
and  reduced,  pale  and  exceedingly  anaemic,  suffering  from  her  first  attack  of 
insanity  of  about  seven  days'  duration.  She  inherited  a  neurotic  tendency  from 
the  father's  side  ;  the  great-grandmother  was  a  paralytic ;  the  father  was  insane ; 
and  the  daughter  was  described  as  being  of  high-strung  ner\'ous  tempera- 
ment. She  had  been  intelligent,  and  had  taken  an  active  interest  in  her  father's 
business  (mercantile) ;  his  late  illness  was  regarded  as  the  exciting  cause  of  her 
attack.  The  patient  had  always  suffered  from  catamenial  irregularities,  and  the 
menses  were  now  completely  suppressed.  Restlessness  and  insomnia  were  followed 
by  hallucinations  of  the  special  senses  and  delusions  ;  she  believed  she  was  to  l>e 
sent  away  as  a  soldier ;  was  pursued  by  a  policeman ;  thought  her  food  was 
poisoned,  and  obstinately  refused  it.  When  brought  to  the  asylum,  her  blood- 
less aspect  was  very  notable,  and  her  physical  prostration  great ;  she  stared 
vacantly  around,  quite  inappreciative  of  her  position  and  relationships,  occa- 
sionally uttered  a  few  articulate  words  or  disconnected  meaningless  sentences, 
and  did  not  reply  to  any  question  asked.  Her  hands  were  decidedly  cold  and 
livid  ;  in  fact,  the  previous  excitement  had  lapsed,  and  a  condition  of  stupor 
existed  ;  the  catheter  had  to  be  regularly  used  before  her  admission.  Port  \v'ine, 
milk  and  eggs,  with  extract  of  beef,  were  given  freely.  Ammonio-citrate  of  iron 
ordered  twice  daily  and  30  grains  of  chloral  when  required  at  night  (chloral, 
however,  was  required  but  seldom,  as  she  soon  obtained  sleep  without  its  aid). 
During  the  whole  of  the  succeeding  month,  patient's  state  was  one  of  extreme 
mental  torpor  and  apathy  ;  she  usually  sat  in  a  half-bent  posture,  utterly  slovenly, 
and  negligent  in  her  habits ;  saliva  dribbling  from  her  mouth ;  her  expression 
vacant,  fatuous ;  the  pupils  were  dilated  and  sluggish ;  the  extremities  blue  and 
cold ;  volitional  effort  was  rare,  and  compulsory  feeding  had  to  be  continuously 
resorted  to.  Occasionally  she  swayed  to  and  fro,  and  gave  utterance  to  a 
piteous  whining  or  a  meaningless  babbling.  This  condition  of  acute  dementia 
continued  for  twelve  months.  Her  Ijodily  health  then  slowly  but  progressively 
improved,  and  during  two  succeeding  months  she  regained  flesh  at  the  rate  of  10 
lbs.  per  month ;  mental  torpor,  however,  still  continued,  and  persistent  amenorrhcea 
was  associated  therewith.     With  this  progressive  physical  improvement  there  now 

of  R.  W,  J.  at  '44.  The  amount  of  haemoglobin,  as  given  by  the  several  cases  at 
page  351,  fluctuates  between  40  per  cent,  and  80  per  cent.  Even  in  the  most  pro- 
found stupor  of  W.  S.  associated  with  habits  of  masturbation  (see  pp.  160,  .351),  the 
percentage  of  haemoglobin  never  fell  below  68  ;  nor  in  any  case  of  simple  uncom- 
plicated stuporose  insanity  have  we  seen  the  colouring-matter  reduced  to  the 
extreme  limits  seen  in  cases  of  haemorrhage.  Thus,  in  the  case  of  M.  A.  M.,  the 
haemoglobin  registered  as  low  as  20  per  cent. 


ETIOLOGY.  343 

appeared  a  gradual  advance  to  more  noi-mal  states  of  consciousness ;  quietly  seated 
in  her  chair,  it  was  noticed  that  she  was  becoming  observant  of  what  passed  before 
her,  and  she  watched  with  apparent  interest,  but  without  assummg  any  further 
initiative,  the  occupation  of  the  patients  around  her,  and  soon  her  blank  staring 
gaze  gave  place  to  occasional  expressions  of  intelligent  recognition,  an  amused 
smile  or  a  play  of  furtive  emotional  states.  Not  until  seventeen  months  had  elapsed 
did  she  begin  to  speak  rationally,  and  about  this  time  the  catamenia  appeared. 
She  beciime  bright  and  lively,  but  still  betrayed  many  morbid  propensities,  and 
was  mischievous,  unruly,  and  excitable.  Her  progress  to  perfect  sanity  was 
interrupted  by  a  short  relapse  ;  but  her  recovery  was  ensured  two  years  after  her 
admission. 

Impulsive  as  these  forms  of  insanity  appear,  our  records  show  few 
of  those  desperate  attempts  at  self-destruction  which  characterise  some 
other  forms  of  insanity.  The  actual  percentage  of  cases  returned  as  suici- 
dal is  high  (40  per  cent.),  whilst  in  male  adolescents  it  falls  to  22  per  cent. 
This  might  lead  one  to  infer  that  the  cases  were  nigh  as  suicidal  as  in 
the  form  of  insanity  prevailing  at  the  climacteric,  when  such  impulses 
are  strongly  developed.  This,  however,  is  not  the  case.  Hysterical 
forms  of  mania  are  prone  to  suggest  or  threaten  such  acts,  but  all  such 
attempts  are  usually  feigned  and  prompted  by  the  morbid  desire  to 
create  sympathy  or  produce  effect.  We  must,  therefore,  not  be  misled 
by  the  fact  that  these  cases  have  committed  outrageous  acts  which 
seem  to  imply  a  suicidal  tendency,  or  have  frequently  threatened  to 
destroy  themselves.  They  are  not  in  the  majority  of  cases  suicidal  in 
the  sense  that  the  subjects  of  puerperal  and  climacteric  mania  are 
suicidal.  On  the  other  hand,  they  are  far  more  likely  to  turn  their 
destructive  efforts  against  others,  and  our  statistics  emphasise  this 
aggressive,  dangerous  tendency  in  48  per  cent,  of  the  female,  and  55*5 
per  cent,  of  the  male  inmates. 

Etiolog'y. — The  excito-motor  exaltation  of  the  nervous  system, 
during  the  first  dentition,  has  also  its  parallel  in  the  explosive 
condition  of  the  nervous  centres  in  higher  planes  of  cerebral  activity 
during  the  evolution  of  the  generative  functions,  and  the  sexual 
divergence  of  the  epoch  of  early  adolescence.  Hence,  this  period  is 
the  second  great  trial  of  the  constitutional  powers  of  the  subject,  and 
is  especially  prone  to  reveal  any  dormant  inherited  vices,  and  call 
them  into  full  activity,  either  as  convulsive  affections  of  the  motory 
apparatus,  such  as  chorea  or  epilepsy,  or  as  psychical  anomalies, 
especially  of  an  hysteric  type.  We  shall  see  further  on,  that  the 
type  of  insanity  which  prevails  at  this  period  of  life  is  essentially 
that  of  an  hysterical  form.  We  have  alluded  to  the  rhythm  of 
nutrition,  that  mysterious  law  which  dominates  the  evolution  of  all 
organic  forms,  vegetable  and  animal  alike,  as  exenipliticd  in  the  high- 
tide  of  infantile   growth ;  the    ebb  of  growing  youth ;   the  renewed 


344  INSANITY    OP    PUBERTY    AND    AD0LE3CENCE. 

flow  at  puberty  and  adolescence  ;  and  the  final  arrest  at  the  maturity 
of  manhood.  Along  this  curve  of  simple  vegetative  growth  appear 
the  pulsations  of  ancestral  influence.  Those  epochs  of  new  develop- 
ments, or  the  points  when  differentiations  occur,  fitting  the  organism 
for  new  or  altered  conditions  of  life ;  the  ancestral  energy,  so  to 
speak,  adapting  the  organism  to  its  altered  environment — dentition, 
puberty,  adolescence,  are  such  epochs.  They  are  characterised 
especially  by  the  tendency  to  reproduce  anCGStPal  developments — 
whether  normal  and  physiological,  or  only  deviations  from  the  laws 
of  health — the  new  character  appearing  at  COPPespondingf  periods 
of  life  in  parent  and  offspring.  Yet  it  must  be  borne  in  mind  that 
ancestral  vices  do  not  necessarily  reappear  in  the  offspring  at  tlie  same 
period  of  life  as  they  appeared  in  the  ancestor,  and  that  then,  "  the 
transmitted  characters  much  oftener  appear  before,  than  after,  the 
corresponding  age."  {Darwin).*  This  law  of  inheritance  has  a  direct 
bearing  upon  the  insane  heritage  of  adolescents,  since,  in  them,  it 
appears  that  with  special  frequency,  we  find  the  ancestral  vice  developed 
late  in  the  life  of  the  parent,  and  to  be  frequently  an  illustration  of 
atavism.  If  we  recall  Darwin's  remarks  on  the  distinction  between 
tPansmission  and  development  of  characters,  we  may  also  more 
readily  comprehend  such  pathological  atavism. 

A  remarkable  persistence  of  any  developmental  vices  at  these 
periods  of  active  life  also  exhibits  itself,  whether  inherited  or  acquired, 
with  which  it  is  well  to  be  acquainted. 

In  this  connection,  it  was  shown  by  M.  Gosselin  many  years  since,  in  a  com- 
munication to  the  Academie  des  Sciences,  that  many  special  surgical  afifections  of 
adolescents  tend  to  persist,  increase,  or  relapse  throughout  adolescence,  but  such 
tendency  is  lost  at  manhood — e.g.,  ingrowing  nail,  valgus  doloureux,  suppura- 
tive epipbysal  osteitis,  epiphysal  exostosis,  subungual  exostosis  of  great  toe,  and 
fibrous  naso-pharyngeal  polypi  will  usually  defy  permanent  cure  tmtil  the  twenty- 
fifth  or  twenty-sixth  year  is  reached,  and  temporising,  therefore,  is  often  called  for 
until  adult  age  is  attained.  + 

Then  again,  it  would  appear  reasonable  to  presume  that  all 
ancestral  tendencies  which  are  transmissible,  would  be  peculiarly 
potent  at  those  periods  when  the  organism  strives  to  reproduce  itself; 
and  that  as  ovulation  occurs  there  would  be  concentred  towards 
Certain  points,  so  to  speak,  the  tendency  to  reproduce  similar 
peculiarities,  <kc.  The  nervous  system  must  necessarily  sympathise 
with  such  conditions,  and  hence  parental  vices,  and  weaknesses — 
insanity,  epilepsy,  chorea — may  be  developed  with  greater  frequency 

*  Descent  of  Man,  chap.  viii.  Variation  of  Animals  and  Plants  under  Domesti- 
cation, vol.  ii.,  1868. 

t  See  Med.  Times  and  Oaz.,  April,  1872. 


ANCESTRAL    INFLUENCE.  345 

at  this  period  of  sexual  divergence  in  the  adolescent.  That  the 
insanity  of  this  period  is  strongly  hereditary,  is  indicated  by  the  fact 
that  40  per  cent,  showed  an  insane  heritage,  and  that  lO'G  per  cent, 
afforded  a  history  of  ancestral  epilepsy ;  and  1)'3  per  cent,  of  apoplectic 
seizures.  It  is  this  genetic  influence  which  so  powerfully  manifests 
itself  at  this  period,  and  especially  towards  the  end  of  adolescence, 
that  forms  the  organised  groundwork  of  the  psychosis,  and  which  we 
regard  as  the  most  important  feature  in  the  evolvition  of  these  forms 
of  insanity ;  for,  given  an  organism  predisposed  by  inheritance  to 
insanity,  such  predisposition  will  tell  with  special  force  at  periods 
of  reproduction  and  development. 

A  related  law  has  long  been  recognised,  viz.,  that  variations  appear- 
ing in  either  sex  before  sexual  divergence  is  well-established,  will 
probably  be  equally  transmitted  to  either  sex  of  the  progeny ;  and 
that  variations  occurring  late  in  life,  when  sexual  divergence  is 
complete,  will  be  transmitted  to  the  same  sex  (Darwin).* 

Taking  the  3,470  cases  of  insanity  in  our  statistics,  we  find  a 
clear  history  of  family  predisposition  to  insanity  in  29-5  per  cent. — for 
the  women,  31-5  per  cent.,  and  for  the  men,  27*2  per  cent.;  hence, 
the  inheritance  by  40  per  cent,  in  the  adolescent  forms  is  a  note- 
worthy feature.  Again  we  find  the  neurotic  inheritance  generally  is 
far  above  what  is  usual  to  all  forms  of  insanity  alike,  as  the  following 
instructive  Table  reveals  : — 


Cases  of  Insanity. 

Hereditary 
Insanity. 

Parental 
Epilepsy. 

Parental 
Apoplexy. 

Parental 
Intemperance. 

3,470  of  both  Sexes,      . 

29-5 

3-68 

3-57 

1,810  Females,      . 

31-5 

3-37 

5-35 

6-6 

1,660  Males, 

27-2 

75  Adolescent  Females, 

40  0 

10-6 

9-3 

160 

It  is,  also,  a  noteworthy  fact  that  the  insanity  incident  to  the  male 
at  this  period  of  life  is  not  (as  it  is  in  the  female)  characterised  by  a 
strongly-marked  heredity,  since  only  27  per  cent,  male  adolescents 
afford  a  history  of  inherited  insanity,  against  40  per  cent,  female 
adolescents ;  the  inherited  tendency,  then,  in  the  male  sex  is  not 
above  that  common  to  all  forms  of  insanity  taken  together. 

On  studying  a  series  of  cases  of  insanity  occurring  in  the  female  at 

this  period  of  life,  we  are  at  once  struck  by  the  paucity  of  cases  in  the 

earlier,  as  compared  with  the  later  years  of  puberty  and  adolescence. 

This  is,  of  course,  what  we  might  have  anticipated.     The  early  period  is 

*  Descent  of  Man,  p.  232. 


346  INSANITY    OP    PUBERTY    AND    ADOLESCENCE. 

one  chiefly  occupied  with  the  active  growtlx  of  the  organism  as  a 
■whole ;  and  it  is  only  towards  the  later  period  (when  this  activity  of 
growth,  subsiding,  allows  the  generative  organs  to  develop,  and  the 
sexual  element  to  force  itself  into  the  mental  life — when,  too,  tracts 
of  cerebral  tissue  come  to  represent  the  reproductive  system  in  all  its 
relationships),  that  the  developmental  tide  may  issue  in  a  stormy 
commotion  of  the  nervous  centres.  This  is  forcibly  illustrated  by  our 
statistics.  Out  of  seventy-seven  cases  occurring  from  the  age  of 
twelve  to  twenty-one  inclusive,  fifty-six  (or  nearly  three-fourths)  were 
from  eighteen  to  twenty-one  years  of  age ;  three  cases  only  occurred 
up  to  the  age  of  fifteen ;  whilst  nine  cases  occurred  in  each  of  the  two 
following  years.  The  age  of  nineteen  and  twenty  was  the  period  of 
greatest  frequency,  hence  the  great  prevalence  of  insanity  was  clearly 
shown  by  these  figures  to  pertain  to  the  years  of  approaching  sexual 
maturity,  coincident  with  that  physiological  cycle  of  mental  evolution, 
which  fits  the  woman  for  the  duties  of  wife  and  mother. 

Ovarian  Derang'ementS. — It  is  important  that  we  here  fully 
understand  the  relationship  borne  by  deranged  states  of  the  sexual 
organs  to  the  mental  anomalies  under  consideration.  Often  is  the 
question  asked  in  cases  of  insanity,  accompanied  by  amenorrhoeal 
states  at  this  period  of  life — Is,  the  menstrual  derangement  the  origin 
of  the  cerebral  disturbance,  a  simple  coincidental  state,  or  the  result 
of  the  nervous  disturbance  ?  If,  however,  we  regard  this  period  as  a 
great  cyclical  developmental  stage,  in  which  the  unfolding  of  the 
generative  system  goes  on,  pari  jjassu,  with  its  representation  through- 
out the  innermost  penetralia  of  the  central  nervous  system,  then  we 
must  regard  the  physical  and  mental  expression  of  this  development 
(the  sexual  characteristics,  bodily  and  mental,  and  the  menstrual  flux) 
as  associated  features,  as  but  the  obvious  signs  of  what  is  going  on 
within  the  pelvis  and  within  the  cranium. 

Menstruation,  then,  as  an  evidence  of  ovarian  maturation  and 
excitement,  and  the  various  secondary  sexual  characteristics  of  hairy 
growth,  irritation  of  the  breasts,  and  the  modified  bodily  conformation, 
must  be  regarded  as  phenomena  occurring  coincident  with  certain  mental 
transformations  in  which  the  girl  becomes  evolved  into  full  womanhood. 
By  no  means  can  they  be  considered  to  be  related  invariably  to  each  other 
as  cause  and  effect;  noi',  moreover,  can  derangements  in  the  functions 
of  the  one  organ  be  spoken  of  as  the  chief  cause  of  derangement  in  the 
functions  of  the  other.  It  can  be  readily  understood  that  persistent 
derangement  in  the  menstrual  flow  must  eventually  lead  (through  de- 
pravation of  blood)  to  nutritive  changes  in  the  nervous  system  expressed 
in  mental  terms;  and  so  also  cerebral  derangements  may  modify  or  arrest 
the  menstrual  molimen  and  flux,  through  the  trophic  system  of  nerves. 


OVARIAN    DERANGEMENTS. 


347 


But  the  arrest  of  the  menses  may  be  due  to  inherent  developmental 
defect  in  the  ovarian  gland  itself;  to  a  primary  vitiation  of  the  circu- 
lating fluid  ;  to  want  of  trophic  energy  centrally  initiated  ;  or,  lastly,  to 
the  influence  of  external  agencies  gaining  access  to  the  economy  in 
some  one  or  other  form.  The  etiology,  therefore,  may  be  of  very  com- 
plex nature ;  and  in  summarily  dismissing  the  case  as  one  of  mental 
derangement  attributable  to  amenorrhoea,  we  should  grievously  err  by 
perhaps  taking  one  indication  of  a  wide-spread  developmental  arrest  of 
ovario-uterine  evolution  as  the  cause  of  a  mental  storm,  which  in  itself 
is  often  but  a  symptom  of  associated  arrest  in  the  development  of 
the  central  nervous  system. 

A.  H.,  aged  nineteen,  a  single  girl,  occupying  the  position  of  housemaid,  had 
been  maniacal  for  four  weeks  before  coming  under  our  observation.  There  was  a 
history  of  a  slight  transient  maniacal  attack  at  the  age  of  seventeen,  which  did 
not  necessitate  asylum  treatment.  She  was  described  as  a  fairly  intelligent  girl, 
of  good  moral  character,  and  no  clue  to  family  neurosis  was  elicited.  She  had 
exhibited  no  eccentricity  prior  to  the  attack,  and  had  suffered  from  no  serious 
illness.  For  a  considerable  period  the  catamenia  had  been  suppressed,  and  her 
health  had  greatly  failed  her.  Her  height  was  5  ft.  4  ins.;  her  weight,  115  lbs. 
The  complexion  was  exceedingly  pale  and  waxy,  and  the  body  generally  most 
exsanguine  in  appearance ;  the  viscera  generally  were  healthy,  but  the  bowels  had 
been  torpid  for  some  time.  At  home  her  excitement  was  intense,  and  she  could 
scarcely  be  restrained  from  rushing  blindly  aboiit  the  house,  shouting  wildly, 
whistling,  or  reading  m  a  loud  tone,  appearing  utterly  regardless  of  decency. 
She  mistook  the  identity  of  all  around  her,  and  did  not  appear  to  recognise  her 
parents.  Under  observation  she  continued  incessantly  garrulous,  but  fairly  coherent 
in  speech.  Her  behaviour  was  flighty,  sudden,  and  impulsive ;  she  sprang  out  of 
bed  repeatedly,  listened  to  imaginary  voices,  and  replied  to  them  ;  was  abrupt  in 
reply  to  questions,  wilful,  and  covered  her  face  with  the  bedclothes.  Her  conscious- 
ness was  greatly  impaired ;  she  failed  to  recognise  the  nature  of  her  surroundings, 
and  evidently  mistook  the  identity  of  those  around  her.  An  aloetic  purge  was 
ordered,  and  a  drachm-dose  of  the  syrup  of  the  phosphate  of  iron  three  times  daQy. 
Fortunately,  her  nights  were  passed  m  quiet  sleep,  and  her  appetite  was  not 
defective.  In  less  than  a  week  there  was  decided  improvement,  all  acute  excite- 
ment had  abated,  and  a  little  flightiness  of  manner  was  alone  perceptible.  She 
was  quiet,  composed,  quite  rational  in  speech  and  conduct ;  complained  much  of 
occipital  headache.  From  this  date  her  health  steadily  improved,  and  in  a  fort- 
night from  admission  she  was  actively  at  work  in  the  needle-room.  She  complained 
much  of  numbness,  with  formication,  and  some  weakness  in  the  lower  extremities ; 
also  of  lumbar  pains  and  occasional  linear  cramps  round  the  abdomen ;  incontinence 
of  urine  was  noted,  and  the  bowels  acted  invohmtarily  at  nirjUt.  These  symp- 
toms apparently  were  due  to  congestion  of  the  cord  and  its  membranes  from 
the  suppressed  menstrual  flow.  Iron  and  aloes,  with  cod-liver-oil  emulsion,  were 
now  ordered,  and  spinal  douches  commenced.  The  patient  subsequently  had  a 
relapse,  preceded  by  increased  occipital  pain  and  depression.  Much  wild  hysterical 
excitement  supervened,  and  she  continued  noisy,  abusive,  and  violently  disposed 
for  the  period  of  a  month,  when  she  again  became  calm,  self-controlled,  and  was 
convalescent  in  three  months  from  her  admission  into  the  asylum.  The  catamenial 
flow  was  re-established  coincident  with  the  greatly-improved  health,  the  spinal 
symptoms  referable  thereto  disappeared,  and  the  patient  was  discharged  recovered. 


348  INSANITY    OP    PUBERTY    AND    ADOLESCENCE. 

It  has  been  already  stated  that  insanity  occurs  in  a  rapidly-increas- 
ing ratio  from  the  age  of  fifteen  to  twenty,  the  three  last  years 
embracing  three-fourths  of  the  total  number  of  cases.  Of  all  these 
cases  57  per  cent,  suffered  from  menstrual  derangements — a  very  high 
proportion — illustrating  the  frequent  association  of  these  conditions. 
If,  now,  we  take  into  consideration  the  relative  female  population  of  the 
county,  and  even  of  the  district,  involved  between  the  ages  of  10  to  15,  of 
15  to  20,  and  of  20  to  25,  we  find  there  is  a  steady  decrease  in  numbers. 
Thus,  the  last  census-returns  give  for  the  West  Riding  of  Yorkshire, 
the  number  of  females  living  at  these  respective  periods,  as  follows  : — 

From  10  to  15  years, 119,023 

„       15   .,   20      „ 109,604 

„      20   ,,  25      „ 104,473 

So,  for  England  and  Wales  together,  the  population  between  the  ages 
10  to  15  and  20  to  28  has  fallen  from  1,398,101  to  1,225,872.  Between 
the  ages  of  13  and  15  we  have  all  the  disturbing  elements  of  puberty 
and  its  incident  changes ;  yet,  though  the  numbers  living  at  this  age 
are  far  greater  than  at  a  later  period,  menstrual  derangements,  associated 
with  cerebral  disturbance,  are  exceptionally  rare,  whilst  after  18  they 
become  extremely  frequent.  The  annexed  table  includes  those  cases 
in  whom  menstrual  derangement  or  notable  anaemia  prevailed  in 
association  with  this  form  of  insanity. 

We  must  bear  in  mind  the  fact  that  every  fresh  development  in  the 
organism  is  attended  by  a  correlated  development  in  the  nervous 
centres  which  represent  the  part ;  and  that  in  no  case  is  this  more 
marked  than  when  the  organism  attempts  to  reproduce  its  kind.  Thus, 
at  the  menstrual  m oilmen,  when  the  germ  is  produced  and  shed, 
whatever  be  the  mysterious  influence  which  leads  up  to  this  effort,  the 
ebb  and  flow  of  the  developmental  tide  is  registered  faithfully  in  the 
nervous  centres  by  a  similar  wave.  At  each  menstrual  molimen  the 
sexual  characteristics  are  more  strongly  emphasised  by  well-recognised 
mental  states ;  and,  a  fortiori,  derangements  amenorrhojal,  dys- 
menorrhoeal,  <fec.,  are  attended  by  deranged  cerebral  functions  correlated 
thereto,  and  the  result  of  discharges  of  grey  matter.  Thus  most  of 
our  cases  clearly  show  exacerbation  of  their  mental  symptoms  at 
pei'iods  corresponding  to  the  natural  monthly  term  when  this  could 
be  ascertained,  either  when  the  flux  was  present,  scanty  or  absent. 
Ovarian  excitation  and  increased  functional  excitation  of  correlated 
nervous  centres  are  set  up  by  the  same  influence;  and  this  influence 
may  expend  itself  sometimes  on  one,  and  sometimes  on  the  other, 
system  almost  exclusively.  It  is  thus  we  find  a  considerable  pi'O- 
portion  of  our  cases  of  insanity  still  unattended  by  any  actual  evidence 
of  deranged  ovario-uterine  functions,  just  as  amenorrhoeal  states  may 
be  unaccompanied  by  serious  mental  disturbance. 


INSANITY    ASSOCIATED    WITH    AMENORRHOiA. 


349 


Insanity  at  Puberty  and  Adolescence,  with  Co-incident  Menstbual 
Derangement  or  Notable  AnjKmia. 


Age. 


Menstrual  Condition. 


10 


11 

18 

12 

16 

13 

19 

14 

20 

15 

19 

16 

19 

17 

20 

18 

17 

19 

20 

20 

20 

21 

20 

22 

19 

23 

20 

24 

16 

25 

17 

26 

19 

27 

18 

28 

20 

29 

18 

30 

20 

31 

20 

32 

15 

33 

16 

34 

18 

35 

20 

36 

19 

37 

16 

38 

17 

39 

16 

40 

18 

41 

19 

42 

17 

43 

18 

44 

17 

45 

19 

46 


17 


Amenorrhcea  for  four  months. 

,,  of  late.  [tack. 

,,  for  eight  months  throughout  at- 

,,  for  eight  months  after  admission. 

,,  throughout  attack. 

,,  for  six  months. 

,,  throughout  attack. 

,,  for  five  months  prior  to  admission 
and  persistent  up  to  discharge. 

,,  for  six  mouths  prior  to  admission ; 
not  re  established  up  to  four 
months  later. 

,,        for  five  months  after  admission. 

,,        persistent  up  to  discharge. 


forfourmonths  preceding  and  three 

months  following  admission. 
for  seven  months  after  admission, 
persistent  throughout  attack, 
of  late,  but  precocious  puberty. 

for  six  months  after  admission. 


„        for  eighteen  months  upon  admis- 
sion. 

, ,        for  ten  months  prior  to  admission. 

, ,         for  four  months  prior  to  admission, 
persistent  throughout  attack. 

,,         history  of  hysteria  for  two  years. 

,,        persists  for   three    months  after 
admission. 

,,         for  three  months  prior  to  and  four 
months  subsequent  to  admission. 

,,        for  three  months  after  admission. 

,,         for  five  months  before  admission, 
and  persistent  up  to  discharge. 

„        for  six  months  after  admission. 
Menstruation  irregular. 


for  many  months. 

and  scanty. 

for  a  short  period. 
,,  regular. 

Amenorrhsea  for  months  prior  to,  and  ir- 
regularity subsequent  to  admission. 

Suppression  or  irregularity  throughout  at- 
tack. 

Menstruation  becoming  for  the  first  time 
established. 

Menstruation  first  established  ten  months 
prior  to  admission  was  suppressed  or 
irregular  throughout  attack. 

Deferred  puberty. 

Deferred  puberty;  catamenia  established 
seven  weeks  after  admission  (recovery). 

Deferred  puberty;  catamenia  not  established, 


Great  mental  stupor. 

Fair  bodily  condition. 
Stout,  approaching  obese. 

Fair  bodily  condition. 

Pallid,  feeble;  wide,  dilated 
pupils. 

Very  pale  and  anaemic. 


Pupils  widely  dilated. 


Thin,  pallid  and  reduced ;  pupils 

widely  dilated. 
"Very  pale,  anemic ;  shows  much 

torpor. 
Very  pale  and  anaemic. 

Pale  and  very  feeble ;  livid  ex- 
tremities ;  "  acute  dementia." 
Pale  and  anaemic;  cold  livid  hands, 


Phthisical. 

Pupils    widely    dilated;    feeble 

health. 
Pale  and  anaemic. 

Wide,  dilated  pupils. 
Extremely  thin  and  reduced. 

Pupils  widely  dilated. 

Very  spare  and  pallid ;  haemic 
bruit;  widely-dilated  pupils; 
much  stupor. 

Very  anaemic :  haemic  bruit. 

Pale  and  chlorotic. 

Profound  waxy  pallor. 
Widely-dilated  pupils. 

Very  pallid,  weakly ;  great  stupor. 
Very  pale  and  anaemic ;  developed 

spinal  disease. 
Very  pale  and  anaemic. 


Extreme  anaemic  pallor. 

Greatly  reduced- 
Stout  and  well-nourished. 


350  INSANITY    OF    PUBERTY    AND    ADOLESCENCE. 

The  development  of  the  organism  is  (at  such  periods  as  we  are  now 
engaged  with)  strongly  affected  by  the  environment  and  employment ; 
social  influences,  and  educational  systems  will  greatly  modify  the 
growth  of  mind  as  it  does  that  of  the  body.  In  either  case  the 
natural  lines  of  development  may  be  blocked  by  unfavourable  social  sur- 
roundings, a  vicious  educational  rule,  or  by  unhealthy  occupations, 
which,  while  they  undermine  the  physique  or  check  its  healthy  expan- 
sion, often  afford  no  food  for  the  mental  life,  but  dwarf  its  stature  and 
cramp  its  unfolding  energies.  The  periods  of  puberty  and  adolescence 
are  peculiarly  prone  to  suffer  thus  in  the  present  day,  when  the  struggle 
for  existence  amongst  the  poorer  classes  often  demands  a  self-imposed 
bondage  of  body  and  mind,  by  which  the  conditions  of  life  are  too 
dearly  purchased.  It  is  amongst  the  poorer  class,  exposed  to  such 
unfavourable  conditions  of  life,  that  we  find  the  worst  forms  of  insanity 
of  the  adolescent  period  prevalent.* 

The  Blood  in  StuporOSe  States. — In  this  connection,  it  is  of 
interest  to  note  the  constant  and  often  profound  implication  of  the 
blood  in  cases  of  adolescent  and  pubescent  insanity,  characterised  by 
a  notable  degree  of  stupor.  The  following  cases  illustrate  forcibly  the 
impoverishment  of  the  red  blood-corpuscle  in  such  subjects  : — 

*  One  of  the  most  glaring  instances  is  presented  by  certain  white-lead  manu- 
factories, where  young  women  are  occasionally  employed  at  an  early  age.  They 
are  continuously  exposed  during  their  employment  to  the  direct  contact  of  the 
metal  with  tlie  skin,  and  to  the  acid  fumes  arising  from  the  stacks.  Their  work  is 
laborious,  irksome,  devoid  of  interest,  and  most  prejudicial  to  health.  The  metal 
is  rapidly  absorbed,  and  produces  profound  changes  in  the  constitution  of  the  blood  ; 
extreme  ansemia  results,  nutrition  is  generally  impaired,  and  the  menstrual 
discharge,  if  not  present,  is  checked  and  suppressed  indefinitely ;  or,  if  it  has 
appeared,  it  becomes  irregular  and  soon  absent.  Lead  colic  is  frequent ;  yet  the 
poor  sufferers  persist  in  their  insanitary  occupation.  Their  pallid  faces,  immature 
growth,  and  arrest  of  the  usual  indications  of  budding  wouiauhood,  gain  for  them 
in  their  neighbourhood  the  sobriqiiet  of  the  "white-lead  ghosts."'  Emijloyment 
here  at  an  early  age,  before  puberty  is  established,  always  results  in  its  arrested 
development,  and  in  indications  of  serious  mal-nutrition  of  the  nervous  centres. 
Hysteric  attacks  are  frequent ;  the  natural  womanly  instincts  are  not  aroused,  or 
are  replaced  by  morbid  sentiments,  unnatural  desires,  and  vicious  habits.  In  place 
of  the  expansion  of  the  higher  emotional  nature  which  befits  her  for  the 
duties  of  womanhood,  and  which  render  her  an  object  of  respect  and  regard  upon 
the  part  of  the  other  sex,  she  remains  a  girl  with  childish  sympathies  up  to 
mature  years ;  or,  sexual  instincts  awakened  into  partial  life,  uncontrolled  by 
higher  emotional  developments,  render  her  an  object  of  aversion  to  others. 
Nervous  derangements  arc  peculiarly  frequent ;  chorea,  epileptiform  seizures, 
cataleptic  states  or  actual  insanity  may  develop. 


THE   BLOOD    IN   STUPOROSE   STATES. 


351 


Amount  of  HyEMOULOBiN  in  Blood  of  Adolescent  Subjects  (Male  and  Female). 

Profoundly  Stuporose. 


«i 


o 


O   3 


RliMARKS. 


C.  W.,     .  Oct.     1,  '87, 
Nov.    2,  '87, 


Dec.     1,  '87, 


Jan.   11,  '£ 


L.  E.  S.,.  Nov.    4,  '87, 

E.  H.,  .  Sep.  28,  '87, 
Oct.  8,  '87, 
Nov.    4,  '87, 

M.  A.  P.,  Nov.  15,  '87, 

H.  S.  L.,  Nov.    2,  '87, 


W.  S.,  .  July  25,  '88, 
July  26,  '88, 
Aug.  2,  '88, 
Aug.  -.i,  '88, 
Aug.  12,  '89, 

R.  W.  J.,  Aug.  10,  '89. 


E.  H.,      .  July  29,  '87, 

T.  T.,      .  Aug.    3,  '87, 

Sept.  28,  '87, 

T.  M.,  .  July  25,  '87, 
July  26,  '87, 
Aug.  2,  '87, 
Sept.  28,  '87, 

M.  B.,     .  Oct.     1,  '87, 


Nov.  15,  '87, 
W.  R.,    .  Mar.    4,  '88^ 


Per 

cent. 

58 

60 


72 


90 


70 

58 
50 

58 

74 

78 


70 
74 
68 
90 
55 


78 
68 

72 

60 
68 
62 

55 

72 


72 
70 


Per 
haemic 

unit. 

94-2 
133-8 


107-8 


115 


107-2 

84-2 
66 
95-8 
93-6 

102-8 


100 
100 
75 
100 
100 
124 


97-2 
95 

85 

115 
126 
105 

82 

lis  6 


84-2 
73-4 


Per 
htemic 
unit. 
-20 
•04 


•10 


•10 


•40 

-22 
-25 

•28 

•22 


•4 
•25 
•25 
•40 

•285 
•18 


•60 
•40 
•20 

•60 
•08 
•40 
•25 

•18 


•22 
•53 


•61 

•45 


•67 


•78 


•64 

•70 

•75 
•61 
•79 

-76 


•68 
-70 
•98 
•68 
•90 
•44 


•80 
•71 

•84 

•52 
•54 
•59 
•67 

•61 


•85 
•95 


Complete  relapse  into  stupor. 

Stupor  of  seven  days'  duration  ; 
catamenia  scanty  fourteen 
days  ago ;  second  time  since 
admission;  face  heavy  antemic, 
lips  blanched,  pupils  normal, 
headache. 

Cheerful  and  active  at  convales- 
cent home;  amenorrhoea;  gums 
ruddy  and  anaemia  decidedly 
lessened. 

During  menstrual  period  ;  cata- 
menia normal ;  lively,  chatty, 
jocular ;  blood  coagulates 
rather  too  readily. 

Great  stupor ;  widely-dilated 
pupils. 

Melancholic  ;  profound  pallor. 

Cheerful  and  lively. 

Intense  melancholia  (lactational) 
compulsory  feeding. 

Considerable  stupor  and  heavi- 
ness ;  yet  works  and  smiles 
when  addressed ;  pupils  large ; 
no  catalepsy  ;  fair  colour. 

Case  oi  profound  stupor  of  several 
years'  duration  ('85,  '89)  re- 
ported at  page  160. 


Quite  mute,  yet  far  less  stupor 
than  on  admission;  no  resist- 
ance, but  shrinks — expression, 
calm  repose. 

Melancholy  with  stupor. 

Hysteric  outbursts  occasional ; 
impulsive,  treacherous. 

Stupor ;  masturbates. 

Stupor  persistent. 

Less  torpid. 

Cheery  and  much  improved ;  far 
less  torpid. 

Relapse  of  hystero-epilepsy, 
fortnightly  scanty  menstrua- 
tion, considerable  pain. 

Catamenia  present,  much  more 
cheei-y  and  communicative. 

Melancholy  ;  profound  stupor. 


352  INSANITY    OF    PUBERTY    AND    ADOLESCENCK. 

In  tlie  Male  Sex. 

Sexual  Diverg'ence. — The  divergence  occurring  at  this  epoch 
does  not  proceed  pari  passu  in  both  sexes,  it  appears  in  the  male 
generally  in  advance  of  the  female  of  the  same  age.  In  the  boy  the 
sexual  instincts  are  earliest  aroused.  In  the  boy  such  instincts  are 
likewise  sublimated  at  an  early  period  of  his  history,  into  higher 
emotional  forms ;  and  during  adolescence  the  progress  made  in  the 
direction  of  intellectual  activities  is  more  apparent,  more  obstrusive 
than  in  the  girl.  The  female  chiefly  exhibits  the  recipiency  of  her 
nature  at  this  epoch,  the  male  its  ppojectivity  in  a  life  of  action; 
the  former  is  the  receptive  organism,  as  the  latter  is  the  effective  and 
distHhutive  one.  In  the  flooding  of  new  areas  of  the  cortex — in  the 
opening  up  of  new  tracts  of  tissue  occurring  during  the  development 
of  the  sexual  organisation  in  woman  as  in  man,*  the  consequent 
differentiation  is  due  not  so  much  to  the  development  proceeding 
entirely  along  a  divergent  tract,  as  in  becoming  more  pronounced  in 
one  direction  than  in  another,  and  in  being  more  advanced  in  the 
male  than  in  the  female.  The  arousal  of  new  instincts,  the  develop- 
ment of  higher  emotional  states — vague  yearnings,  wide-spread  sym- 
pathies, tender  passions,  half-understood  promptings — bespeak  in 
woman  a  high  subjectivity,  devoted,  however,  to  the  most  generous 
ends.  In  man,  on  the  other  hand,  the  expansion  of  the  amiable 
qualities  is  never  so  great;  his  love  is  from  the  first  of  a  more 
selfish  nature,  and  its  further  developments  are  likewise  devoted  to 
more  selfish  ends.  More  calculating,  more  ingenious,  more  inventive, 
his  schemes  and  plans  of  action  from  the  first  must,  from  the  very 
constitution  of  society,  embrace  antagonism  to  his  fellow-man  in  the 
competition  and  race  for  life.  The  dependence  of  the  one  sex  is  notably 
in  contrast  with  the  self-reliance  of  the  other.  Thus  Darwin,  alluding 
to  sexual  distinctions,  says  : — 

"  Woman  seems  to  differ  from  man  in  mental  disposition,  chiefly  in  her  greater 
tenderness  and  less  selfisliness  ;  and  this  holds  good  even  with  savages.  .  .  . 
Woman,  owing  to  her  maternal  instincts,  display's  these  qualities  towards  her 
infants  in  an  eminent  degree  ;  therefore  it  is  likely  that  she  would  often  extend 
them  towards  her  fellow-creatures.  Man  is  the  rival  of  other  men,  he  delights  in 
competition,  and  this  leads  to  ambition,  which  passes  too  easily  into  selfishness. 
These  latter  qualities  seem  to  be  his  natural  and  unfortunate  birth-right."  + 

These  considerations  would  in  themselves  suffice  to  indicate  the 
divergence  in  type  of  mental  ailment  to  which  the  two  sexes  are 

*  The  correlation  of  these  coincident  developments  is  seen  in  the  fact,  that  if  man 
be  emasculated,  the  sexual  characteristics  never  appear  (Darwin,  op.  dt.,  p.  557). 
t  Descent  of  Man,  chap.  xix. 


SEXUAL    DIVERGENCE.  353 

exposed  at  this  period  of  life.  Whilst  the  female  shows  a  prepon- 
derating effect  on  the  affective  sphere  of  mind,  the  adolescent  youth 
J>etrays  an  aberrant  tendency  in  the  reactive  faculties  of  his  mental 
being.  His  newly-awakened  faculties,  like  all  nascent  mental  products, 
are  wondrously  fresh,  active,  and  potent ;  hence,  naturally  tending 
to  falsify  relationship  from  want  of  a  due  contrasting  power,  his 
powers  and  abilities  are  vastly  exaggerated,  and  beget  an  unfortunate 
egoismus.  His  plots  and  schemes  savour  of  the  wildest  vanity ; 
whilst  the  self-complacent  all-sufficiency  with  which  he  reveals  these 
plans  betoken  the  overpowering  of  normal  contrasting  experiences  by 
the  new-begot  factors.  Every  faculty  whereby  he  becomes  a  unit  of 
power  in  the  domestic  or  social  circle  is  represented  in  false  quantities, 
and  a  disproportionately  intensified  and  overweening  self-esteem  is 
the  natural  outcome.  The  sexual  divergence  at  this  immature  age 
certainly  tells  in  favour  of  the  gentler  sex.  The  male  adolescent  has 
had  his  characteristics  faithfully  rendered  by  the  amiable  satire  of 
Thackeray  in  the  person  of  Pendennis,  whilst  his  frailties  have 
received  less  consideration  at  the  hands  of  Carlyle.* 

The  aiflative  emotional  states,  the  newly-awakened  instincts,  the 
flood  of  new  impressions,  and  the  sense  of  widely-expanding  faculties, 
constitute  a  physiological  sta^^e  of  development  which  is  natural  to 
all  at  this  period  of  their  life.  Its  obtrusiveness  will  always  be 
more  or  less  noted ;  manly  sports  and  exercises,  with  a  moderate 
use  of  the  intellectual  faculties,  will,  however,  do  much  to  carry 
ofi"  the  overflowing  mental  energy  in  a  healthy  channel ;  but  of 
all  ftiults,  that  of  introspection  and  subjectivity  at  this  age  should 
be  avoided.  A  false  code  of  morals  does  much  to  foster  this  ten- 
dency, and  has  much  to  answer  for  in  the  intensification  of  mental 
anomalies  in  youth.  Need  we  recall  the  religious  asceticism  of 
the  Middle  Ages  as  confirmatory  of  this  fact  1  A  transitional  epoch, 
such  as  this,  is  surely  not  a  suitable  period  for  self-analysis;  and 
this  is   emphasised   by  the  well-known  fact  that   youths,  encouraged 

*  "  I  have  heard  it  affirmed  (surely  in  jest)  by  not  unphilanthropic  persons,  that 
it  were  a  real  increase  to  human  happiness,  could  all  young  men  from  the  age  of 
nineteen  be  covered  under  barrels,  or  rendered  otherwise  invisible,  and  there  left  to 
follow  their  lawful  studies  and  callings,  till  they  emerged  sadder  and  wiser  at  the 
age  of  twenty-live.  With  which  suggestion  as  a  practical  scheme  I  nowise 
coincide.  Nevertheless,  it  is  plausibly  urged,  that  as  young  ladies  are  to  mankind, 
precisely  the  most  delightful  in  those  years,  so  young  gentlemen  do  then  attain  their 
maximum  of  detestability.  Such  gawks  ai'e  they,  and  foolish  peacocks,  and  yet 
such  vulturous  hunger  for  self-indulgence,  so  obstinate,  obstreperous,  and  vain- 
glorious ;  in  all  senses  so  froward  and  so  forward." — Sartor  Eesartus,  "Getting 
under  way." 

23 


354  INSAN'ITY    OK    PUBERTY    AXD    ADOLKSCENCE. 

at  this  period  by  misguided  parents  or  tutors  to  lead  a  too  studious 
sedentary  life,  devoid  of  healthsome  exercise,  and  to  subject  their 
mental  life  to  a  pseudo-religious  training,  embracing  rigid  introspec- 
tive exercises,  lapse  readily  into  the  worst  forms  of  mental  derange- 
ment, and  indulge,  above  all  others,  in  secret  sins  and  sexual  vices. 

This  period  witnesses  the  profound  changes  of  complete  sexual 
divergence,  and  the  attainment  of  those  mental  chai'acteristics  which 
distinguish  the  one  sex  from  the  other.  The  late  epoch  is  charac- 
terised by  certain  important  features,  which  especially  map  it  out  as 
the  earliest  marriageable  period  free  from  special  risks,  and  has, 
therefore,  been  termed  the  period  of  nubility  {Matthews  Duncan). 
This  author  shows  us,  that,  if  we  compute  the  number  of  first  births 
in  newly-marvied  women  at  difi"erent  ages,  we  shall  find  that  the 
greatest  "initial  fecundity"  occurs  between  the  ages  of  twenty  and 
twenty-five.  Precocious  marriages  expose  the  mother  to  the  risks  of 
death  in  child-bed,  or,  if  she  survive,  predispose  to  the  bearing  of  an 
excessive  number  of  children. 

In  women,  the  changes  occurring  in  the  pelvic  bones  from  puberty 
forward  are,  of  course,  of  vital  importance,  and  illustrate  well  the 
immaturity  of  the  ossific  skeleton  for  the  full  functions  of  maternity 
up  to  the  age  of  twenty. 

Symptoms. — The  subject  usually  comes  before  us  excited,  highly 
elated,  his  attitude,  demeanour  and  expression  indicative  of  intense 
self-complacency  and  assurance.  The  excitement  may  be  very  acute, 
attended  with  continuous  garrulity,  incoherence  and  movement,  yet 
the  buoyancy  of  spirits  is  a  striking  feature  at  all  times.  In  the  more 
coherent  states  the  subject,  unprompted,  reveals  his  exalted  notions ; 
talks  of  his  acquirements  as  a  scholar;  expatiates  on  his  skill  as  a 
workman;  revels  in  the  supposed  possession  of  rare  and  much-esteemed 
faculties,  of  persuasive  eloquence,  of  poetic  talent,  of  wondrous  vocal 
powers,  of  the  gift  of  tongues,  of  artistic  abilities,  or  histrionic  powers 
of  a  high  order ;  or  his  thoughts  course  in  the  direction  of  his 
muscular  energies  and  capacities,  he  assumes  his  strength  to  be  almost 
superhuman,  and  regards  himself  as  a  champion  walker,  runner, 
wrestler,  or  the  like  {F.  S.,  p.  291). 

Even  if  such  beliefs  are  not  definitely  expressed,  egoistic  sentiments 
prevail,  and  are  the  fount  from  which  issue  extravagant  schemes  of 
action.  Inventiveness,  ingenuity,  cunning,  are  all  assumed  by  this  alien 
being,  whose  mental  life  is  awaking,  though  in  an  anomalous  form, 
to  the  appreciation  of  the  keen  competition  of  existence.  We  observe 
a  similar  condition  arise  at  a  later  period  of  life,  in  that  fatal  malady 
general  paralysis ;  but  here,  to  account  for  the  symptoms,  there  is  a 
far  more  profound  structural  alteration,  which  progressively  becomes 


SYMPTOMS    OP    PUBESCENT    INSANITY.  355 

more  and  more  involved,  until  utter  fatuity  and  paralysis  result ;  yet 
in  the  eai-ly  stages  of  this  disease  the  same  egoism,  the  same  lofty  ideas 
of  the  subject's  physical  powers,  wealth,  capabilities,  ingenuity  and 
skill  come  to  the  fore. 

Towards  their  own  sex  this  self-assumed  superiority  calls  forth  often 
an  aggressive  conduct,  an  overbearing  manner  amounting  to  arrogance, 
which  involves  them  in  frequent  disputes  and  quarrels.  To  the 
gentler  sex  their  behaviour  is  often  gallant  and  condescending,  sav- 
ouring of  a  precocious  manliness  which  does  not  accord  with  their 
mental  and  physical  development.  As  Dr.  Clouston  states  : — "  In 
the  males  heroic  notions,  imitation  of  manly  airs  and  manners,  an 
obtrusive  pugnaciousness,  and,  sometimes,  a  morbid  sentimentality 
Avere  present."  *  And  again  : — "  The  physical  appearance  of  the  males 
Avas  boyish,  and  of  the  females  girlish."  On  the  other  hand,  it  must 
not  be  forgotten  that  such  adolescent  forms  of  insanity  are  prone  to 
prurient  thoughts  and  erotic  promptings  which  make  them  objects  of 
anxiety  to  their  guardians  in  relation  to  the  other  sex.  All  the  above 
symptoms  are  liable  to  intensification  by  the  vicious  habit  of  mastur- 
bation still  further  reducing  the  nutrition  of  the  nervous  centres ; 
above  all  agencies  does  it  prove  most  powerful  in  leading  up  to  chronic 
delusional  insanity,  or  into  hopeless  dementia. 

The  cases  of  insanity  occurring  from  puberty  to  the  completion 
of  adolescence  naturally  arrange  themselves  under  two  categories  : — 

(«.)  There  are  those  in  whom  maniacal  excitement  (often  very 
intense)  prevails,  with  the  egoistic,  self-laudatory  state  alluded  to ;  and 
often  alternating  with  conditions  of  mental  stupor  and  cataleptic  states. 

(b.)  And  there  are  those  of  a  later  age,  in  whom  delusionS  are  the 
prominent  characteristic — delusions  more  often  associated  with  mel- 
ancholic depression  than  with  maniacal  excitement. 

In  fact,  the  proportion  of  delusional  cases  occurring  between  the 
ages  of  twenty-one  and  twenty -five  is  far  greater  than  that  which 
occurs  between  thirteen  and  twenty-one.  It  has  already  been 
remarked,  that  cases  of  melancholic  depression  are  of  far  less  frequent 
occui'rence  in  the  female  than  in  the  male  adolescent,  and  since 
adolescence  is  completed  in  the  female  earlier  than  in  man,  age 
possibly  has  much  to  do  with  its  predominance  in  the  later  adolescence 
of  the  male  sex.  Our  statistics  indicate,  that  of  all  cases  of  insanity 
apparently  influenced  by  adolescence  in  men,  i.e.,  from  the  age  of 
fourteen  to  that  of  twenty-five,  inclusive,  about  one-half  occur  up  to 
twenty-one  years  of  age,t  and  the  remainder  subsequently ;  or,  to  be 

*  Lectures  on  Mental  Diseases,  p.  552. 

t  From  the  age  of  thirteen  to  that  of  seventeen  there  were  iO  cases  of  insanity 
out  of  a  total  of  3,000. 


356  INSANITY   OP    PUBERTY   AND    ADOLESCENCE, 

exact,  142  occurred  before  twenty-one,  and  135  afterwards  and  np  to 
twenty-five  years  of  age.  As  in  women,  so  in  men  we  find  that  there 
is  a  rapidly-increasing  number  of  cases  from  the  age  of  fourteen  up 
to  that  of  twenty-one. 

As  modified  by  the  vice  of  masturbation,  we  find  tlic  prevalence  of 
pseudo-religious  exaltation,  indulgence  in  cant,  and  development  of 
fixed  religious  delusions.  One  patient  conceived  himself  transformed 
into  the  Almighty;  another  believed  he  was  inspired  by  spiritual 
agency  and  could  perform  miraculous  works;  another  had  the  gift  of 
tongues.  Then  come  periods  of  great  impulsiveness  (often  prompted 
by  visual  and  aui'al  hallucinations),  sudden  ferocious  violence,  indecent 
assaults  ujjon  the  other  sex,  and  even  suicidal  acts  of  determined 
character,  attempts  at  rape,  strangling,  drowning;  these  are  not  i;nusual 
features  in  the  masturbatic  adolescent.  The  type  is  by  no  means  always 
that  characteristic  of  the  ordinary  sane  masturbator,  for,  though  the 
jihysical  symptoms  of  cerebro-spinal  irritation  may  be  equally  pro- 
minent in  both,  yet  the  mental  ailment  borders  more  often  on  that  of 
delusional  insanity.  The  shy,  averted  look,  timidity,  obsequious- 
ness, and  shunning  of  society,  may  be  replaced  by  a  bold  audacious 
bearing,  a  shameless  confession  (and  even  defence)  of  their  habit,  a 
shocking  disregard  of  decency,  and  an  entire  absence  of  the  sense 
of  moral  degradation.  Even  if  the  vice  be  concealed,  the  pale 
ansemic  aspect,  the  dark  areola  around  the  eyes,  the  dilated  pupil 
and  the  general  atony  exhibited  in  feeble  heart  and  languid  circula- 
tion, enfeebled  motor  power  and  disturbed  co-ordination,  the  amnesic 
states,  occipital  headache  {Sjntzica),  the  vague  unreasonable  alarm, 
eccentric  dislikes  fostered,  and  unfounded  suspicions,  soon  attract 
our  attention. 

J.  M. ,  aged  nineteen,  labourer;  admitted  June,  1S82,  A  paternal  uncle  died 
demented;  a  second  cousin,  S.  M.,  is  at  present  a  patient  in  this  Institution — no 
intemperance.  J.  M.  had  been  addicted  to  masturbation  since  the  age  of  fourteen, 
and  though  conscious  after  some  time  of  its  prejudicial  effects,  was  unable  to  discon- 
tinue its  indulgence.  During  the  four  years  preceding  his  admission  to  the 
asylum  he  grew  more  and  more  despondent,  brooding  ever  over  his  Bible  and 
Prayer-book,  neglecting  his  work,  and  wandering  abstractedly  about  the  fields. 
This  condition  was  interrupted  by  longer  and  shorter  remissions,  but  finally 
settled  into  a  permanency  of  deep  depression,  the  outcome  of  which  appeared, 
some  five  months  before  being  put  under  care,  in  a  successful  attempt  to  emasculate 
himself.  Immediately  on  its  performance  lie  had  two  convulsive  seizures,  not, 
however,  recurring.  A  short  period  of  mental  improvement  followed,  and  then 
he  became  worse  tlian  ever.  Three  years  befoi'e  this  occurrence  he  had  had  a 
fall  from  a  hayloft  upon  his  head. 

When  admitted,  he  was  tearful  and  much  depressed,  but  communicative.  His 
object  in  castration  was  ''to  prevent  the  jiossibility  of  masturbation,"  but  the 
object  attained,  he  was  overcome  by  fear  of  having  "cut  himself  off  from  God, 


MODIFIED    FORMS — CASE    OF   J.    M.  357 

and  lost  his  soul."  This  belief  he  maintained  during  his  residence,  but  became 
nevertheless  more  slightly  oppressed  by  it,  less  gloomy  and  despondent,  and 
decidedly  improved  in  some  points  inasmuch  as  he  employed  himself  actively, 
and  showed  sociability.  Was  sent  to  home-care  at  the  expiration  of  fourteen 
weeks.  Of  the  interval  of  twenty  months  which  preceded  his  second  attack,  the 
first  eight  were  spent  satisfactorily  on  the  whole,  although  occasional  relapses 
occurred ;  the  ensuing  twelve  months  witnessed  a  gradual  deterioration  of  his 
condition,  ending  in  a  return  of  his  despondency,  with  some  outbursts  of  violence. 
When  brought  back  to  the  asylum  he  was  much  depressed,  partly  by  his  religious 
fears,  partly  by  his  regret  at  having  emasculated  himself;  he  disclaimed  suicidal  tend- 
ency. Considerably  hypochondriacal  for  a  few  weeks,  he  then  made  really  steady 
improvement,  and  became  active,  conversable,  and  easy  in  his  mind  regarding  his 
future.  Was  discharged  "recovered"  at  the  end  of  four  months.  He  kept  fairly 
well  for  about  five  months  ;  but  during  the  next  two,  he  fell  again  into  a  state  of 
depression,  brooding,  and  occasional  turbulency. 

Tlie  same  prominence  was  not  given  to  religious  sentiment  in  this  attack,  but 
he  expressed  his  belief  that  it  was  his  duty  and  God's  will  that  he  should  blow 
up  London.  No  further  delusion  was  manifested,  nor  suicidal  inclination  acknow- 
ledged ;  he  always  maintained  a  taciturn,  moody  expression,  and  evinced  much 
hypochondriacal  feeling.  At  times  he  expressed  himself  as  hopeless  of  his  future 
salvation,  &c. ,  but  these  phases  were  short,  and  probably  not  of  such  real  intensity 
as  on  previous  occasions.     Convalescence  occurred  after  the  lapse  of  ten  months. 

A  fresh  recurrence  took  place  a  month  after  his  discharge,  and  he  showed 
suspicious  and  violent  tendencies.  This  attack  was  characterised  by  continuous 
sullen,  quarrelsome,  vindictive  conduct,  and  utter  refusal  to  employ  himself, 
for  the  greater  part  of  the  time.  Was  wont  to  stand  in  a  corner  of  the 
room,  staring  blankly  in  front  of  him,  with  his  hands  in  his  pockets,  and  to 
become  violent  and  abusive  if  disturbed,  and  even  so,  without  any  provocation. 
Pwequired  forcible  alimentation.  On  one  occasion  he  was  found  to  have  tied  his 
neckerchief  tightly  around  the  scrotum,  producing  much  cedema.  After  twenty 
months'  care  showed  no  improvement.     He  was  transferred  to  Menston, 

"Without  attempting  any  refined  analysis  of  the  multifarious  groups 
which  might  be  comprised  under  the  head  of  insanities  at  adolescence, 
still  less  att(^.mpting  to  dignify  with  specific  significance  the  varied 
symptoms  of  such  groups,  it  will  best  serve  the  purpose  of  the  student 
to  direct  his  attention  to  the  symptoms  proper  to  insanity  at  this 
l)eriod  of  life,  and  to  the  modifying  influence  of  vicious  habits  of  life, 
e.g.,  masturbation  and  drink;  intercurrent  afiections,  such  as  phthisis; 
or  defective  states  of  the  blood,  as  in  anaemia.  And  first,  let  us  draw 
the  distinction  clearly  between  the  forms  of  insanity  arising  during 
adolescence,  and  those  subject  to  the  modifying  efli'ects  of  masturbation. 

In  drawing  such  a  distinction  we  must  keep  in  mind  the  fact  that 
the  vice  is  so  frequent  that  a  pure  xmcomplicated  form  of  insanity  at 
this  period  of  life  is  the  exception,  not  the  rule.  As  already  stated,  a 
great  proportion  of  our  adolescent  cases  are  found  to  be  mild  cases  of 
congenital  defect,  and  these  are,  as  is  well  known,  prone  to  the  vice. 

Again,  the  period  of  life  is  prone  to  induce  the  habit  in  a  case  of 


358  INSANITY    OP    PUBERTY    AND    ADOLESCENCE. 

insanity  of  any  standing,  even  if  the  subject  were  not  previously 
acUlicted  thereto ;  and  in  the  later  stages  of  such  unfavourable  cases  as 
lapse  into  dementia,  the  habit  almost  invariably  exists. 

In  a  pure  uncomplicated  form  of  insanity  at  adolescence,  we  find  the 
patient  in  a  state  of  sub-acute  or  acute  excitement,  with  exalted  self- 
feeling.  His  egoism  (which  is  the  prominent  feature)  is  like  that  of 
the  victim  of  general  paralysis  in  its  obtrusive  aspects ;  there  are 
notions  of  wealth,  superabundant  enei'gy  and  power,  enviable  dis- 
tinctions and  rank,  a  general  feeling  of  bien  etre ;  or  the  youth  may 
have  wondrous  plans  in  view,  exhibit  restless  energy,  incessant 
scheming,  yet  withal  he  shows  a  frank,  bold,  generous  bearing  wholly 
distinct  from  that  worn  by  the  masturbutor.  He  is  garrulous, 
obtrusive,  often  objectionably  so  to  his  elders,  yet  there  is  nothing  of 
a  repulsive  character.  His  egoism  is  ever  tending  outwards  towards 
the  realisation  of  his  phantom  schemes  j  there  is  no  self-engrossment 
and  abstraction.  His  egoism,  again,  has  more  self-confidence,  and 
appears  as  a  self-assertiveness  and  assurance,  so  well  grounded  in  the 
patient's  sentiments  and  beliefs,  that  opposition,  dissent,  restriction 
appear  impossible,  or  too  contemptible  to  be  taken  into  account ; 
there  is  not  the  fear,  suspicion,  hatred  of  the  environment  fostered 
by  the  other  form.  Then  again,  the  physical  symptoms  due  to  the 
vice  are  absent  in  the  uncomplicated  form.  The  recoverability, 
again,  of  insanity  at  adolescence  is  very  great ;  the  prognosis  in 
insanity  modified  by  onanism  is  veiy  grave ;  in  fact,  the  majority 
of  unfavourable  cases  of  the  former  are  accounted  for  by  the 
frequent  lapsing  into  this  habit.  As  modified  by  the  vice,  however, 
the  mental  symptoms  are  those  of  a  narrow  repulsive  egoism, 
flavoured  by  pseudo-religious  hypochondriasis,  often  with  much  shy- 
ness and  reserve  at  first,  but  later  on,  obtrusive  and  unseemly 
{F.  S.,  p.  291).  The  pseudo-pietistic  notions  early  developed,  long 
before  marked  mental  derangement  is  actually  recognised  by  the 
patient's  friends,  are  of  the  most  cramped  and  selfish  nature.  Obsti- 
nate narrow  bigotiy  often  results  in  a  complete  intellectual  famine,  the 
patient  becoming  a  prey  to  some  sectarian  community,  which  succeeds 
only  too  well  in  checking  the  due  expansion  of  the  moral  nature,  and  in 
fostering  the  self-opinion  and  conceit  of  its  victim.  We  find  the  parents 
often  speak  of  such  an  one  as  of  deeply-pious  habits  of  thought  and  life, 
as  eminently  conscientious,  as  of  an  amiable,  modest,  and  retiring 
nature,  failing  wholly  to  realise  the  deep-seated  egoism  and  self- 
contemplative  abstraction  which  lies  beneath  such  natures. 

"With  this  morbid  subjectivity  there  is  often  associated  much  timidity, 
unexplained  dread,  tremblings,  frightful  dreams  and  "  nightmares," 
often  hysteric  seizures.     In  the  intellectual   sphere  there  is  a  great 


ETIOLOGY.  359 

want  of  spontaneity,  lack  of  energy  and  mental  movement,  which  may 
border  on  imbecility;  irritability,  spasmodic  temper,  impulsive  conduct 
alternate  with  gloom,  despondency,  torpor ;  the  mood  is  very  variable. 

Then,  again,  hallucinations  of  sight  and  of  hearing  very  fi-equently 
prevail ;  and  often  explain  the  timidity  and  terror  of  such  cases.  The 
physical  symptoms  are  no  less  striking  than  the  mental,  and  bespeak 
the  wide-spr-ead  exhaustion  of  the  cerebro-spinal  centres.  Such 
symptoms  are— the  ansemic  aspect,  associated  with  general  atony ; 
the  dilated  pupil ;  the  languid  circulation  and  vasomotor  paresis ; 
cold  blue  extremities,  a  sense  of  weakness  in  the  lower  extremities, 
and  a  slightly  ataxic  gait,  often  swaying  and  inco-ordinate  movements. 

We  thus  see  that  the  symptoms  indicative  of  the  psychosis,  inci- 
dental to  this  period  of  life,  are  far  different  to  those  aroused  by  the 
vice  of  masturbation.  The  egoism  and  afflative  state  of  the  maniacal 
adolescent  are  readily  recognisable,  but  their  symptoms  undergo 
varied  modification  and  intermixture  upon  addiction  to  this  vice. 
Thus,  when  we  find  the  adolescent,  instead  of  improving  rapidly,  makes 
several  partial  recoveries  only  to  relapse,  and  especially  when  such 
relapses  are  towards  mental  torpor  with  general  lack  of  muscular 
energy  and  vascular  tone,  we  at  once  suspect  addiction  to  this  vice. 
So  when  we  find  the  averted  glance,  the  widely-dilated  pupil,  the 
expression  and  demeanour  indicative  of  efi'eminate  self-engrossment, 
and  delusions  based  on  the  sexual  instincts,  indications  of  sexual 
pel-versions  or  intensified  egoism,  we  naturally  look  for  a  similar 
origin.  Aural  hallucinations,  timidity,  distrust,  loss  of  self-confidence, 
with  this  concentration  of  the  self-feeling  are  all  harbingers  of  the 
same  vicious  habit. 

EtiolOg'y. — A  very  large  proportion  of  the  cases  of  acute  excitement 
are  constituted  by  congenitally-weak  minds,  and  the  number  of  such 
cases  which  precede  the  age  of  twenty-one  is  nearly  double  that  of  those 
which  follow ;  in  fact,  the  age  of  puberty  and  adolescence  is  peculiarly 
the  trial-period  for  subjects  of  congenital  defect — then,  if  at  all,  will 
their  deficiencies  become  notably  prominent.  This  remark  does  not 
necessarily  apply  to  cases  wanting  in  intellectual  aptitude,  but  rather 
to  those  with  the  defective  moral  control  which  characterises  so  many 
of  our  cases  of  congenital  weakness.  The  whole  moral  being,  as  we  have 
seen,  is  subjected  at  this  period  to  revolutionary  changes  through  the 
incoming  of  new  sensations  and  the  turmoil  produced  by  this  inter- 
penetration  of  the  old  self;  new  sentiments  spring  into  life,  fresh- 
begotten  emotions  (redundant  in  energy)  tend  to  further  ovei-throw 
canons  of  belief;  and  the  judgment  is  strongly  swayed  by  such  overbal- 
ancing factors.  At  this  period,  if  at  any  time,  is  a  duly-balanced  moral 
control  necessaiy  to  the  well-being  of  the  subject.     How  often  it  fails 


360  INSANITY    OF    PUDERTY    AND    ADOLESCENCE. 

is  too  flagrant  a  fact  to  be  dwelt  upon.  How  much  of  such  failure  is 
due  to  immature  and  narrow  systems  of  education,  to  vicious  and 
cramping  customs  of  life,  and  to  injudicious  parental  training  is  also 
only  too  apparent.  Of  the  most  vital  importance  is  it  that  the  lines 
of  development  of  the  moral  nature  at  this  critical  epoch  should  be 
watched  with  the  greatest  interest,  and  that  the  parental  and  tutorial 
guidance  should  be  of  the  most  enlightened  and  prospective  kind,  to 
insure  the  due  integration  and  elaboration  of  the  chaotic  mass  of 
impressions  incrowding  at  this  stage  of  mental  evolution.  It  is  out  of 
such  misguided  states  arise  the  religious  fanatic,  the  sordid  sensualist^ 
the  repulsive  masturbator,  the  nerveless  sentimentalist,  and  the 
vicious  and  impulsive  characters  who  are  to  the  end  moral  wrecks, 
bearing  witness  through  their  lives  to  the  violence  and  tyranny  of  the 
adolescent  storm.  It  is  the  epoch  of  great  moral  convulsions,  which  in 
the  insane  is  accountable  for  those  extraordinary  delusional  concepts 
of  a  religious  character,  which  (even  in  the  insane)  have  so  bizarre  an 
effect.  The  ideas  of  being  crucified  or  of  being  subjected  to  martyr- 
dom of  a  revolting  kind,  of  being  transformed  into  the  Almighty, 
exemplify  the  kind  of  notions  which  readily  spring  into  life  at  this 
epoch  in  those  who  become  alienated.  Such  conceptions,  it  may  be 
noted,  would  be  scarcely  possible  at  a  much  earlier  age ;  they  deal 
with  the  subject-matter  of  late  periods  of  development,  the  material  of 
religious  doctrines  and  sentiments,  and  therefore  indicate  an  early 
denudation  of  evolving  mind.  Prior  to  the  mental  commotion  of 
puberty  these  moral  imbeciles  have,  maybe,  shown  an  aptitude  for 
learning,  a  brightness  of  intelligence  proportionate  to  their  age,  and 
little  (beyond  an  ill-governed  passion,  or  vicious  or  cruel  tendencies) 
to  indicate  the  approaching  danger.* 

When  the  sexual  instincts  are  aroused  at  piiberty,  their  dwarfed 
morale  renders  them  easy  victims  to  the  vice  of  masturbation,  which, 
perhaps,  is  the  best  criterion  of  defective  moral  control.  If  persisted 
in,  it  no  longer  remains  the  symptom  of  a  mental  defect,  but  the  prolific 
source  of  a  deepening  malady  of  the  nervous  centres,  whereby  the  mental 
affection  is  itself  coloured.  Masturbation,  as  a  symptom  of  disease,  is,  of 
course,  prevalent  in  insanity  at  all  pei-iods  of  life;  but  adolescence  is 
the  epoch,  especially,  when  its  indulgence  is  apt  to  be  the  exciting  cause 
of  a  grave  developmental  malady,  which  otherwise  might  have  been 
tided  over.  We  have  on  moi'e  than  one  occasion  watched  the  advent 
of  puberty  in  the  successive  members  of  a  highly-neurotic  family  where 
insanity,  drink  and  apoplexy  had  been  the  ancestral  curse,  and  have 
seen  one  after  the  other  succumb  to  this  epoch  of  their  life,  the  vice 

*  See  also  on  this  subject  Dr.  Hack  Tuke.  Psychological  Medicine:  Art., 
"  Pubescent  Insanity." 


ILLUSTRATIVE   CASES    OF    ADOLESCENT    INSANITY.  361 

being  successively  engendered  as  the  sexual  instincts  came  to  the  fore. 
There  are  few  physicians  who  do  not  meet  with  numex'ous  instances  of 
this  class. 

The  explosiveness  of  nerve-tissue  in  the  imbecile  is  a  characteristic 
feature  of  their  case,  and  we  can  conceive  no  condition  more  likely  to 
issue  in  the  impulsive  forms  of  insanity  than  that  of  a  vicious  imbecile 
arriving  at  the  period  of  puberty  and  a  victim  to  a  perverted  sexuality. 

The  two  following  cases  are  typical  instances  of  the  insanity,  incident  to  the 
period  of  adolescence,  with  its  alternations  of  stupor,  and  of  wild  maniacal  excite- 
ment and  dangerous  impulsiveness  :— 

L.  C,  aged  twenty,  single,  a  clerk  in  a  merchant's  office.  Had  previously  been 
insane  for  five  months  at  the  age  of  eighteen  and  was  then  strongly  suicidal.  He  has 
been  always  anxious  since  this  attack  lest  he  might  take  his  own  life  some  day.  A  few 
days  prior  to  his  admission  he  had  become  peculiar,  reserved,  depressed,  and  showed 
much  failure  of  appetite ;  and  on  the  previous  night  he  went  to  bed  and  stabbed 
himself  in  the  chest  (though  not  dangerously)  with  his  penknife.  His  health  in 
other  respects  had  been  good  ;  there  was  no  neurotic  history  ;  no  personal  history 
of  drink  or  cranial  injury.  He  was  of  average  height,  somewhat  thin  and  reduced  ; 
his  complexion  was  pale  and  pasty  ;  his  pupils  were  dilated  and  mobile.  He  had  a 
heaAy,  listless  expression,  averted  his  face  during  conversation,  was  evasive  and 
flippant  in  rei)ly.  He  at  times  assumed  a  languid  affected  air ;  and  his  mental 
operations  were  slowly  performed  :  he  was  reticent,  depressed,  and  sighed  deeply. 
He  was  suspected  to  be  addicted  to  masturbation,  and  this  suspicion  was  fully 
confirmed  on  admission ;  his  vicious  habits  were  most  inveterate,  and  all 
remedies  tried  for  the  purpose  of  reducing  this  tendency  completely  failed.  The 
patient  made  a  most  determined  indecent  assault  iipon  a  female  the  day  after  his 
admission.  He  remained  dull  and  lethargic,  in  a  state  at  times  amounting  to 
stupor ;  took  no  interest  in  anything  occurring  in  his  ward ;  was  careless  in  his 
habits,  but  at  times  wilfully  mischievous.  Suddenly,  however,  after  several 
months  of  stupor,  he  asked  for  a  pipe  of  tobacco,  spoke  cheerily,  rationally,  and 
began  to  sing  an  old  air,  play  dominoes,  and  read.  He  attributed  his  own  improve- 
ment to  his  discontinuance  of  his  vicious  habits. 

P.  C,  aged  twenty-three,  a  labourer,  but  intelligent,  was  admitted  for  his 
first  attack  of  insanity,  from  which  he  had  suffered  for  three  days  past.  The  onset 
was  very  sudden,  and  quite  unexpected  by  his  friends.  He  had  worked  as  iisual 
up  to  eight  o'clock  one  evening.  On  returning  home  he  became  obstinately 
silent,  and,  on  retiring  to  bed  with  his  brother,  he  attacked  the  latter  savagel}-, 
smashed  the  pictures  on  the  walls,  &c.  He  has  been  maniacally  excited  since, 
shouting,  laughing,  and  singing  aloud ;  proclaims  himself  the  second  Messiah,  at 
other  times  another  Saint  Patrick,  and  broke  a  hole  through  the  ceiling  (as  he 
explained)  "  to  let  the  Devil  out."  On  admission  he  was  very  furioiis,  was  haggard 
and  exhausted  in  appearance,  and  required  compulsory  feeding.  Milk  and  egg, 
with  brandy  and  soda-water,  were  immediately  given  him,  and  feeding  had  to  be 
resorted  to  for  two  days,  during  which  period  the  excitement  continued  unabated 
and  he  passed  sleepless  nights.  Six  ormces  of  brandy  have  been  given  liim  daily 
with  milk  and  egg  and  lieef-tea.  He  has  had  the  succus  conii  in  four-draelim  doses 
three  times  daily.     The  third  morning  after  his  admission  a  qiiiet  night  and  peace- 


362  INSAXITV    OF    PUBERTY    AND    ADOLESCENCE. 

ful  sleep  were  reported,  and  he  took  his  breakfast  voluntarily.  He  was  now  able 
to  converse  and  give  a  coherent  account  of  himself  and  his  feelings.  He  stated 
that  he  had  been  recently  attending  religious  services,  and  that  they  had  "opened 
up  his  mind  more  clearly  to  religious  truths."  He  then  began  to  feel  that  all  his 
movements  were  prompted  by  "inspiration,"  and  things  around  looked  different ; 
the  face  of  every  one  he  looked  at  brightened  up.  When  he  attended  the  con- 
fessional subsequently,  upon  stating  that  he  did  not  drink,  a  voice  intimated  to 
him  that  he  would  go  to  Heaven ;  and  he  at  once  Ijecame  tilled  witli  a  supernatural 
joy.  His  religious  fervour  now  passed  into  feelings  of  great  excitement,  during 
which  he  often  believed  himself  to  be  crucilicd  with  his  head  downwards.  On  one 
dark  night  the  room  became  suddenly  lit  up  by  spectral  lights,  and  voices  were 
heard  by  him  frequently  when  he  could  see  no  one  present.  He  believed  that  his 
own  rambling  talk  were  the  utterances  of  the  Almighty.  There  was  no  history  of 
hereditary  epilepsy,  or  of  drink.  He  had  taken  very  special  interest  in  the  Catholic 
missions,  just  about  the  time  when  he  became  maniacal.  He  was  still  a  little  hazy 
and  confused,  but  quite  rational,  when  giving  the  above  account  of  himself.  From 
this  period  he  made  a  steady  recovery,  and  was  discharged  in  five  weeks  without 
a  relapse. 

Prognosis. — Of  all  types  of  insanity  that  occurring  at  the  puerperal 
period  is  one  of  the  most  recoverable  (80  per  cent.),  yet  the  recovery- 
rate  is  nearly  as  high  for  the  insanity  incidental  to  adolescence;  in  the 
female  sex  the  mania  runs  a  course  of  some  months,  usually  marked 
by  one  or  more  relapses,  but  one  half  of  the  cases  recover  by  the  seventh, 
and  neai-ly  three-fourths  are  well  by  the  tenth  month.  {See  Chart  B.) 
It  is  far  otherwise  with  the  same  affection  amongst  men;  in  them, 
■where  (as  alread}^  stated)  depression  is  often  largely  present,  the 
prognosis  is  far  less  favourable,  and  a  wide  margin  must  be  allowed 
for  partial  recoveries,  chronic  incurables,  and  fatal  cases.  On  com- 
paring the  percentage  of  recoveries  in  puerperal,  adolescent  male  and 
female  cases,  the  above  statement  is  fully  verified,  thus : — 

Puerperal         Adolescent         Adolescent 
Cases.  Females.  Males. 

Kecovery-rate  per  cent.,         .         .         SO'O  73'3  oS'4 

A  glance  at  the  following  table  of  results  of  treatment  in  either  sex, 
■will  indicate  in  no  uncertain  terms  the  more  unfavourable  nature  of 
this  form  of  insanity  in  the  male  sex : — 


Recovered.  Believed.  "  ,"^,°  ; .  Died. 


Remained 
as  Chronic. 


Female  adolescents  per  cent.,    .         73 '.S  7'G  13 "5  5 "4 

Male  adolescents  ,,  .         5S'4  14  4  17*3  9'7 

The  unfavourable  cases  form  2G-5  per  cent,  of  the  total  number  of 
cases  in  females,  and  41-4  in  males. 

We  have  already  alluded  to  the  actual  recoverability  of  this  form  of 
insanity  in  its  i-elationship  to  sex;  it  will  also  repay  us  to  observe 
more  particularly  the  duration  of  the  attack  up  to  cure  in  both  sexes, 


PROGNOSIS  AND  RECOVERY-RATE.  363 

in  other  words,  the  recovery-rate  as  affected  by  time.  [See  Chart  B.)  If 
for  this  purpose  we  glance  at  the  chart  of  recoveries  first  as  regards 
the  male  adolescent,  it  will  be  evident  that  during  the  first  six  weeks 
but  ten  cures  will  result  out  of  a  total  of  one  hundred  and  sixty-two: 
during  the  next  fortnight  an  addition  of  ten  recoveries  just  doubles 
this  number,  and  then  for  the  third,  fourth,  and  fifth  months  a  rapid 
inci'ement  of  cures,  viz.,  seventeen,  fourteen,  and  twenty-five  respec- 
tively; so  that  the  summit  of  the  curve  is  I'eached  at  the  fifth  month,* 
bij  which  jyeriod  nearly  one-half  the  total  member  of  cases  have  recovered. 
Then  a  sudden  drop  midway  occurs  for  each  month  from  tlie  sixth  to  the 
ninth  inclusive — i.e.,  from  ten  to  twelve  cases  for  each  month  respectively. 
From  this  time  up  to  twenty  months  the  monthly  cui've  once  only 
rises  above  four,  being  usually  much  lowei",  and  a  few  rare  and  unex- 
pected cures  occur  (as  in  other  forms  of  insanity)  at  later  periods  still. 

Now  the  curve  of  recovery  for  females  differs  considerably  from  the 
foregoing,  being  less  abruptly  broken,  being  more  uniform  and  sus- 
tained in  the  early  half  of  the  period  of  recoverability,  f  and  exhibiting 
beyond  this  but  one  abrupt  elevation;  also  by  the  critical  period,  if  by 
this  term  we  may  so  name  the  period  of  greatest  recoverability,  occur- 
ring from  the  fourth  to  the  seventh  month,  and  not  as  in  the  male 
subject  from  the  third  to  the  fifth.  From  this  it  results,  that  whereas 
one-half  the  male  recoveries  are  established  by  the  fifth  month,  nearly 
seven  months  elapse  ere  a  proportionate  number  of  females  recover.  The 
second  abrupt  rise  of  eleven  cases,  and  as  sudden  a  fall  shown  at 
the  tenth  month  in  the  female  chart,  I'eproduces  in  a  modified  form  the 
sustained  recovery-rate  shown  between  the  sixth  and  ninth  months  in 
male  adolescents.  From  such  a  chart  we  might  augur  that  the  chances 
of  recovery,  apart  from  any  specially-favourable  points  inherent  in  the 
case,  are  equally  good  between  the  fourth  and  seventh  months  from 
onset;  that  if  from  some  unfavourable  element  in  the  nature  of  the 
case  recovery  does  not  then  take  place,  a  further  hope  may  be  enter- 
tained of  recovery  at  the  tenth  month,  beyond  which  the  chances  are 
greatly  reduced ;  and,  also,  that  if  a  male  adolescent  is  not  included  in 
the  favoux'able  list  of  cures  up  to  the  fifth  month,  we  may  still  hope  on 
with  reasonable  expectation  of  recovery  to  the  ninth  month,  beyond 
which  the  case  must  be  regarded  as  assuming  a  serious  character,  and 
the  outlook  is  certainly  ominous. 

Not  only  are  the  cases  prior  to  the  age  of  twenty-one  more  often 

*  It  must  be  remembered  that  the  period  dealt  with  in  these  cliarts  is  that  bc- 
tM'cen  actual  onset  of  Insanity  and  recovery. 

t  The  period  of  recoverability  may  be  arbitrarily  fixed  at  twelve  months  from 
the  onset  of  the  insanity ;  the  few  recoveries  subsequent  to  this  date  not  militating 
strongly  against  the  utility  of  this  doctrine. 


3G4  IXSAXITY    OF    PUBERTY   AND   ADOLESCENCE. 

characterised  by  excitement,  but  the  type  of  insanity  then  prevalent 
is  distinctly  a  more  recoverable  form ;  the  recoveries  in  the  earlier  con- 
trasting with  those  in  the  later  period,  as  ninety-one  to  seventy-one. 
In  other  words,  if  we  group  together  the  partial  recoveries,  the  f\xtal 
cases,  and  the  chronic  remnant  as  the  unfavourable  class,  we  shall  find 
that  such  a  class  constitutes  31  per  cent,  of  the  acute  forms  of  insanity, 
and  49  per  cent,  of  the  melancholic  forms;  in  fact,  the  chronic  cases  are 
double,  and  the  partial  recoveries  ("  relieved ")  more  than  double  in 
the  melancholic,  that  which  obtains  in  the  maniacal  forms. 

Treatment. — The  simpler  forms  of  hysteric  excitement  occurring  at 
this  jieriod  often  do  not  call  for  other  than  moral  and  dietetic  measures; 
removal  from  the   home    circle   and  possible  sources  of  irritation  to 
entirely-novel  relationships,  the  administration  of  a  due   amount  of 
aliment,  regular  habits  of  life,  and  means  to  ensure  sleep  will  often 
suffice  to  eflfect  a  cure.     Nourishment  should  be  given  in  an  easily- 
assimilable  form,  its  nature  dictated  by  our  knowledge  of  the  systemic 
wants  at  this  developmental  phase  of  the  patient's  life.     The  secretory 
and  excretory  organs  should  be  especially  attended  to,  liable  as  they 
are  at  these  periods  to  derangement  and  sluggish  action.     Sleep  should 
be   secured  by  out-door  exercise,   active  employment,   commensurate 
with  the  patient's  powers  of  endurance  within  the  limits  of  absolute 
fatigue;  sedatives  should  be  studiously  avoided.     It  is  only  when  pro- 
longed insomnia  persists  for  several   nights  together,  in  spite  of  the 
abov-e  measures,  that  sedatives  are  admissible,  and  then  a  single  dose 
of  chloral,  sufficiently  large  to  ensure  absolutely  the  desired  amount  of 
rest,  may  be  given;  its  frequent  administration  for  this  purpose  is  to 
be  strongly  dejjrecated.     In  such  cases  as  inherit  a  strongly-neurotic 
temperament,  and  in  which  the  cycle  of  developmental  change  has  not 
resulted  in  much  physical  over-strain  and  wear  and  tear,  large  doses  of 
potassium  bromide  (30  to  60  grains  three  times  daily)  may  be  admin- 
istered with  decided  benefit  so  long  as  a  due  amount  of  wholesome 
food  can  be  taken.     Most  often  we  have  to  deal   with  the  menstrual 
irregularities   of  this   epoch   and   its   attendant   anaemia,   our  subject 
having    succumbed   to    the    developmental   wave;    the   nutritive  and 
assimilative  capacities  having  been  overtaxed  by  the  exaggerated  de- 
mands of  the  gi'owing  organism.       Here  a  strictly-hygienic  regimen 
should  be  carefully  and  persistently  enforced,  such  as  out-door  exercise 
and  the  spinal  douche  or  sponge-bath.     Iron,  especially  the  carbonate, 
should  be  given  in  pill  or  mixture.     It  is  well  to  vaiy  the  form  of 
iron,  occasionally  administering  it  in  the  form  of  iron-and-alocs  pill; 
or  as  the  ammonio-citrate;  or  as  the  sulphate  of  iron  in  combination 
with  extract  of  nux  vomica  and  rhubarb  in  pill;  or  again  as  the  com- 
pound syrup  of  the  phosphates  with  malt-extract  and  cod-liver  oil. 


CHART    of    RECOVERIES  m    FEMALES. 
PUBERTY    &   ADOLESCENCE. 


Chart  B 


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CHART  of    RECOVERIES    in  MALES. 


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Recov'  Relieved  Died  Remaininj 

162        40         27         48 

584%     I44°i      9-7!.      17  3% 


IUrationilfAttacl(.4iv  6w  2/»   3     4     5     6    7     8     9    10    II     12    13    14   15    20  2y   3y 


SYMPTOMS   OP    PUERPERAL    INSANITY.  365 


INSANITY  AT  THE   PUERPERAL  PERIOD. 

Contents. — Symptoms — Predominance  of  Mania — Intensity  of  the  Morbid  Process- 
Obtrusive  Sexual  Element — Hallucinations — Delusions  of  Suspicion — Prevalence 
of  Suicidal  Feelinj^s — Etiology — Susceptibility  of  the  Puerperal  Period — Illegiti- 
macy and  Puerperal  Insanity — Frequency  in  Primiparae — Condition  of  the 
Blood — Diminution  of  Hajmoglobin  —  Prognosis  —  Treatment  —  Insanity  of 
Pregnancy — Relatively  Infrequent — Primiparfe  show  uo  S^jecial  Liability — 
Symptoms — Recoveries. 

Symptoms. — The  onset  may  be  absolutely  sudden,  following  upon 
delivery  ;  but  more  frequently  the  development  is  gradual,  being  pre- 
ceded by  evidence  of  nervous  exhaustion,  until  the  fully-matured 
disease  bursts  out  in  all  its  fury  at  the  end  of  the  first  week  succeeding 
labour.  The  patient  suffers  from  early  insomnia,  becomes  restless, 
fidgetty,  unnaturally  gai'rulous  ;  she  exhibits  a  waywardness  not 
customary,  takes  strange  and  unreasonable  dislikes,  especially  towards 
her  husband,  or  refuses  to  have  her  infant  brought  to  her.  There  is  a 
furtiveness  of  glance  auguring  a  suspicious  state  of  mind,  a  startled 
look  on  the  slightest  sound,  or  even  intolerance  of  light.  All  her 
relatives  observe  a  change  of  disposition,  and  perhaps  attribute  it  to  a 
wilful  temper  merely,  but  the  pulse  becomes  hurried  and  small,  the 
face  pale  and  haggard,  the  eye  startlingly  bright.  She  cannot  be  in- 
duced to  sleep,  or  sleep  is  broken  by  distui'bing  dreams,  from  which 
she  starts  up  in  bed  rambling  in  disconnected  utterances.  Then  come 
hysteric  outbursts,  extravagant  conduct,  and  all  the  features  of  an 
acute  maniacal  attack.  The  presence  of  delusions  and  hallucinations 
declare  themselves,  she  shouts  aloud  to  imaginary  persons,  listens  to 
their  voices,  rejects  her  food  with  repugnance,  declaring  it  to  be 
poisoned. 

Maniacal  excitement  usually  characterises  these  outbursts ;  out  of 
68  puerperal  cases  as  many  as  45  or  66  per  cent,  suffered  from  mania, 
whilst  states  of  depression  prevailed  in  23  patients  or  33-8  per  cent. 
If  we  associate  with  these  the  cases  which,  originally  puerperal,  had 
been  allowed  to  suckle  their  infants  for  some  time  after  symptoms  of 
mental  alienation  had  been  observed,  we  get  from  a  total  of  111  as 
many  as  74  or  66  per  cent,  as  subjects  of  mania,  and  nearly  the  same 
proportion,  30  per  cent.,  as  subjects  of  melancholia. 

The  mental  afiection,  then,  at  this  stage  is  essentially  an  acute 
maniacal  state,  in  which  there  is  intense  excitement,  great  incoherence, 
continuous  garrulity,  and  a  dangerous  explosiveness,  which  may  issue  in 
most  desperate  impulsive  conduct;  there  is,  moreover,  a  special  pi-o- 
clivity  to  indulgence  in  obscene  language,  indecent  exposures  of  the 
person,  and  genuine  nymphomaniacal  states ;  or  the  deep-rooted  erotic 


366  INSANITY    AT    THE    PUERPERAL    PERIOU. 

feelings  may,  partially  controlled,  reveal  themselves  in  the  sudden 
gestures,  or  sensiial  glances,  or  prurient  demeanour  in  a  less  obtrusive 
manner. 

There  is,  despite  the  adverse  view  of  high  authorities  upon  this 
point  [Gooch,  Marce,  Fuville),  abundant  evidence  in  support  of  the  view 
that  this  sexual  element  stamps  the  insanity  of  parturition  and  the 
early  i)nerperal  period  with  features  whicli  demand  special  attention ; 
but  whether  such  features  should  exalt  the  mental  affection  into  a  dis- 
tinct nosological  entity  is  very  doubtful,  and,  in  our  opinion,  unjusti- 
fiable from  considerations  already  appealed  to.* 

Hallucinations. — Visual  and  aural  hallucinations,  or  both  com- 
bined, occur  to  the  almost  complete  exclusion  of  other  forms  of  sensory 
disturbance  ;  in  fact,  17  per  cent,  of  our  puerperal  cases  exhibit  such 
anomalies — the  average  for  the  total  admissions  in  all  forms  of  insanity 
being  29  per  cent.  This  is  not  so  high  an  estimate  as  that  of  Dr. 
Clouston,  who  also  assumes  the  aural  to  be  the  more  frequent;  in  our 
experience  they  occur  in  about  equal  frequency.! 

Delusions. — Quite  63-2  per  cent,  showed  obvious  delusions  of  very 
varied  chai-acter,  but  chiefly  tending  towards  ideas  of  persecution,  the 
patient  believing  herself  the  victim  of  intrigues  at  the  hands  of  her 
nearest  relatives — her  husband,  children,  her  former  friends  and  neigh- 
bours ;  her  life,  or  that  of  her  children,  is  threatened,  or  some  terrible 
tragedy  is  being  enacted ;  in  two  cases,  the  house  was  believed  to  be 
haunted.  Ideas  of  poisoning  are  prominent  featui'es,  the  food  being 
frequently  rejected  upon  this  plea.  Another  not  infrequent  delusion 
was  that  of  a  sexual  nature ;  the  husband's  fidelity  was  called  in 
question,  or  there  were  ideas  that  men  entered  her  bedroom  at  night 
for  illicit  purposes  ;  one  patient  believed  herself  to  have  been  confined 
of  twins  who  were  falling  into  a  canal.  In  five  cases  the  subject 
believed  herself  eternally  lost,  forsaken  by  God,  and  given  up  to  the 
machinations  of  the  evil  one.  This  delusion  that  the  soul  is  lost  was 
as  fi-equent  as  in  forms  of  insanity  of  a  more  melancholic  type,  occurring 
later  on  during  lactation  ;  in  fact,  religioiis  delusions  were  frequent. 
Hypochondriacal  delusions  were  not  observed  in  a  single  case. 

To  take  a  brief  summary  of  some  of  the  more  important  hallu- 
cinations betrayed  by  puerperal  cases  : — 

Faces  besmeared  with  blood  peep  through  tlie  windows  ;  spirits  hover  around  ; 
angels  and  devils  surround  the  bed  ;  the  patient's  deceased  mother  confronts  her, 
and  mysterious  lights  flit  about  the  room  ;  voices  are  heard  ;  the  form  of  the  evil  one 
appears ;  or  they  shout  aloud  to  imaginary  voices ;  sounds  are  heard,  interpreted 
as  conspirators  beneath  the  building ;  or  a  voice  within  prompts  her  to  suicide. 

*  See  also  on  this  point  Dr.  Sankey's  Lectures  on  Insanity,  pp.  128,  195. 
t  Vide  Lectures  on  Mental  Disease,  p.  507. 


DELUSIONS    OF   SUSPICION — SUICIDE — ETIOLOOY.  367 

From  tlicsc  considerations  it  will  be  obvious  that  the  general  tone 
of  feeling  is  that  of  distPUSt  and  suspicion,  implicating  her  conjugal 
relationsliips,  her  friends,  and  former  associates,  or  as  affecting  her  moral 
well-being ;  or  utter  failure  of  self-confidence  and  delusions,  sometimes 
of  a  most  harrowing  description,  based  thereupon. 

Suicide. — We  have  alluded  to  the  explosiveneSS  of  the  disease, 
and  the  tendency  to  impulsive  acts  is  a  most  notable  feature  in 
insanity  at  this  period.  Attempts  to  murder  the  offspring  have  been 
frequently  recorded,  and  no  woman  suffering  from  this  form  of  insanity 
should  be  brought  into  close  i-elationship  with  her  children.  About 
25  per  cent,  presented  active  suicidal  propensities ;  but  nearly  double 
this  proportion,  or  47  per  cent.,  were  impulsively  dangerous  to  those 
around  them.  The  suicidal  impulse  was  often  prompted  by  delusion  ; 
thus,  one  patient  believed  her  husband  wished  to  cut  her  throat,  and, 
consequently,  sprung  from  her  bedroom  window.  Another  leapt  from 
her  window  under  the  impression  that  her  husband  had  just  murdered 
his  two  children,  and  under  similar  impi-essions.  One  case  tries  to 
end  her  days  by  a  desperate  attempt  at  strangulation,  and  another  by 
cutting  her  throat. 

The  various  forms  of  mental  disturbance  found  at  this  period  may 
be  thus  classified  in  the  order  of  their  frequency  of  occurrence  : — 


Acute  mania,  .... 

31  cases 

Melancholia,  with  delusions,  . 

13      „ 

Mania,  with  delusions,    . 

7      ,, 

Simple  mania, 

7      ,, 

Simple  melancholia, 

8      „ 

Acute  melancholia. 

1      ,, 

Melancholy  with  stupor, 

1       „ 

68      ,, 

EtiolOg'y. — It  would  be  indeed  strange  if,  at  a  peiiod  embracing 
such  revolutionary  changes  as  are  comprised  in  the  onset  of  labour 
and  the  first  half  of  uterine  involution,*  the  mental  stability  was 
not  endangered  beyond  the  average  usual  at  the  same  period  of  life 
in  the  non-parturient.  So  numerous  are  the  novel  relationships  into 
which  the  nervous  system  then  enters,  and  so  powerful  are  the  new 
agencies  brought  to  bear  as  excitants  to  morbid  reaction,  that  subjects 
hei'editarily  predisposed  to  insanity,  must  necessarily  incur  imminent 
risks  at  this  crisis  of  their  histoiy.  As  Burrows  says : — "  Gestation 
itself  is  a  source  of  excitation  in  most  women,  and  sometimes  provokes 

*  The  term  "puerperal  mania"  is  arbitrarily  assigned  to  the  mental  derange- 
ment occurring  during  the  first  six  weeks  of  the  jnierperal  state  ;  involution  of  the 
uterus  being  usually  not  complete  for  three  months. 


368  INSANITY    AT   THE    PUKUPKKAL    PEUIOIx 

mental  derangement,  and  more  especially  in  those  with  a  hereditary 
predisposition.""* 

Let  us  consider  what  are  the  peculiar  circumstances  which  favour 
such  issues.  First,  there  is  the  mental  transformation  incident  to 
this  latter  period  of  gestation  ;  the  arousal  of  maternal  instincts, 
especially  for  the  first  time,  is  frequently  associated  with  unstable 
states  of  nerve-centres,  issuing  in  introspective  states,  exalted  self- 
feeling,  voluminous  emotional  waves,  vague  fears  of  impending 
troubles,  and  often  hysteric  outbursts.  Such  conditions  must  be 
attributed  to  the  eccentric  irritation  of  the  gravid  uterus,  as  well  as 
to  the  deteriorated  state  to  which  the  maternal  blood  has  succumbed  ; 
and,  unless  the  depurative  processes  become  more  active,  nutritional 
anomalies  are  liable  to  arise,  producing  undue  nervous  instability 
during  gestation  and  subsequent  to  parturition.  If  the  functions 
of  secretion  and  excretion  be  checked,  as  by  loaded  bowels,  or  the 
accumulation  of  morbid  products  in  the  blood,  a  source  of  irritation 
to  the  nervous  system  at  once  appears ;  and,  if  albuminuria  coexist, 
the  urcemic  state  of  the  blood  may  tend  towards  actual  convulsion.! 
Then  come  the  physical  and  moral  shock  of  labour,  the  emotional 
tension,  and  recoil  of  this  crisis ;  and,  lastly,  the  immediate  and 
more  remote  consequences  (local  and  general)  of  parturition. 

The  physical  and  moral  shock  is  ever  a  varying  quantity ;  but, 
in  all  cases,  nervous  exhaustion  is  always  attendant  on  such  an 
enormous  outlay  as  is  demanded  during  parturition,  especially  in 
those  constitutionally  enfeebled,  reduced  by  the  ailments  of  the  later 
stages  of  gestation,  by  insomnia,  or  by  a  tedious  protracted  labour, 
or  attendant  haemorrhage.  The  moral  shock  is  regarded  as  an  all- 
powerful  excitant  to  mental  ailments  of  this  period,  as  illustrated  in 
cases  of  illegitimacy ;  and  authorities  have  constantly  drawn  attention 
to  the  prevalence  of  puerperal  insanity  amongst  those  who  have 
borne  illegitimate  offspring.  "Esquirol  speaks  of  a  sort  of  frenzy 
incident  to  unfortunate  girls  in  giving  birth,  in  misery  and  secrecy, 
to  bastard  children ;  a  condition  of  mind,  which  it  is  to  be  feared, 
often  prompts  either  infanticide  or  suicide." | 

Again,  subsequent  to  labour,  we  have  the  whole  uterine  surface 
exposing  the  system  to  the  perils  of  haemorrhage  by  imperfect 
contraction,  to  retention  of  excretory  products,  to  the  absorption  of 
septic  agencies,  metritis,  phlebitis,  and  its  attendant  evils.  Later, 
still,  come  the  evils  due  to  imperfect  depui'ative  processes,  requisite 

■*  Commentaries,  p.  3G3. 

t  The  urajmic  element  in  the  causation  of  puerperal  eclampsia  lias  been  called 
in  question ;  see,  however,  the  very  apposite  i-emarks  by  Dr.  Gowers  in  his 
Biicases  of  the  Nervotis  System,  vol.  ii.,  p.  71C.      i  Burrows'  Commentaries,  p.  3C4. 


PUERPERAL   INSANITY   AND    ILLEGITIMACY'.  3G9 

fov  the  removal  of  adventitious  products  during  the  slow  involution 
of  the  uterine  muscle ;  the  fatty  disintegration  of  the  giant-fibre,  and 
its  replacement  by  the  nucleated  fibre-cell,  which  prevailed  in  the 
nulliparous  state.  The  products  of  such  disintegi-ation  found  copiously 
in  the  lochia,  and  probably  as  the  fatty  elements  in  the  ui-ine,  and 
caseous  elements  of  the  early  mammary  secretion,  will,  if  these 
secretory  and  excretory  functions  be  arrested,  lead  up  to  the  evils 
now  alluded  to.  In  fact,  the  whole  puerperal  period  is  one  of 
extPeme  susceptibility.*  The  explosive  condition  of  the  nerve 
centres  is  at  its  height  during  parturition,  and  it  is  then,  especially, 
that  eccentric  irritation  of  the  cerebrum  may  lead  to  transient 
psychical  anomalies,  or  to  the  motor  discharges  of  general  eclampsia 
convulsions ;  and  it  seems  but  a  question  of  individual  susceptibility, 
or  intensity  of  the  eccentric  irritation,  which  determines  the  one  or 
the  other,  the  psychical  often  preceding  the  convulsive  phenomena. 
Thus,  at  the  acme  of  a  supreme  uterine  effort,  and  especially  during 
the  passage  of  the  head,  if  large,  in  excitable  primiparse,  the  intensity 
of  the  pain  is  often  accompanied  by  complete,  though  transient, 
alienation,  by  grave  reductions  in  consciousness,  by  rambling  inco- 
herent talk,  by  outrageous  and  impulsive  actions — the  new-born 
infant  may  be  sacrificed  to  the  mother's  frenzy,  f 

Illeg'itimacy. — I  have  already  drawn  attention  to  Esquirol's  state- 
ment of  the  prevalence  of  insanity   amongst   those  who  have  been 
illegitimate  children;  it  has  also  been  shown  by  Dr.  Clouston  that  this 
cause  is  a  potent  factor  in  Scotland — where  illegitimacy  abounds.     He 
estimates  that  25  per  cent,  of  his  cases  occurred  where  the  offspring 
were  illegitimate.     When  we  take  our  English  asylums  into  considera- 
tion, the  results  are  far  different;  illegitimacy  is  far  less  rife;    and  it 
appears  that  out  of  a  total  of  sixty-six  cases  sixty-one  were  married, 
and  the  children  l^orn  in  legitimate  wedlock,   whilst  in   seven  only 
were  the  patients  unmarried  women.     Now  the  proportion  of  single  to 
married  patients  in  the  total  admissions  of  1,810  cases  was  35  per  cent, 
to  50  per  cent,  respectively ;  hence  the  proportion  of  10  per  cent,  of 
single  women  who  sufiered  from  puerperal  insanity  is  exceptionally  low. 
Frequent  in  Primiparae. — Frequent  child-bearing  has  apparently 
no  connection  with  the  development  of  insanity;    of  the  sixty-eight 
puerperal  cases,  twenty-two  were  first  confinements,  or  a  percentage  of 
32'3;  20*5  per  cent,  had  had  two  children  ;  10  per  cent,  and  14  per  cent, 
respectively  had  had  three  and  four  children;  and  of  those  who  had  fami- 
lies ranging  between  five  and  nine,  22  per  cent,  were  also  represented. 

*  Burrows,  op.  cit.,  p.  3GG. 

t  There  is,  likewise,  a  temjiorary  delirium  sometimes  accompanying  difficult 
labours,  in  the  fever  on  the  secretion  of  milk,  or  the  inflammation  of  the  breasts. 
Burrows,  lb.,  p.  364. 

2i 


370 


INSANITY    AT   THE    PUERPERAL    PERIOD. 


Second  attacks  occurred  in  eight  cases,  of  whom  two  were  primiparae 
and  the  remaining  six  had  families  ranging  from  two  to  nine.  No  case 
liad  suffered  from  a  third  seizure. 

The  Blood  in  Puerperal  Insanity.— Tested  by  the  ha?moglobino- 

motcr  the  amount  of  lufinoglobiu  was  found  below  the  normal,  as 
indicated  by  the  series  of  observations  recorded  in  the  following 
table : — In  the  case  of  R.  W.  J.  it  amounted  to  but  55  per  cent.,  and 
in  C.  C.  to  60  per  cent,  of  the  standard  of  healthy  blood ;  in  two  other 
cases  it  varied  between  74  per  cent,  and  78  per  cent.  The  first  case  or 
the  tabulated  series  {M.  A.  M.)  in  which  profound  ansemia  had  resulted 
from  post-j-)artum,  haemorrhage,  gave  upon  one  occasion  as  low  a  per- 
centage as  20,  rising  subsequently  to  32  per  cent. 

The  corpuscular  richness  (numerical)  in  the  uncomplicated  cases  came 
near  that  of  normal  blood,*  being  80-6  to  124  per  hsemic  unit — 
i.e.,  from  4,030,000  up  to  6,200,000  corpuscles  per  cubic  millimetre ; 
but,  the  corpuscular  value  estimated  in  hsemoglobin  was  invariably 
low — the  lowest  register  being  44  in  the  case  of  R.  W.  J.,  the  other 
three  subjects  giving  -75,  -76,  and  "79  respectively  of  the  normal  value. 
In  the  case  of  J/.  A.  J/.,  however,  the  numerical  corpuscular  richness, 
commencing  at  2,680,000,  fell  to  2,040,000,  and  eventually  rose  to  3i 
million  corpuscles  per  millimetre  cube  ;  the  corpuscular  value  at  one 
time  but  -35  rose  to  -68  and  subsequently  fell  to  -60  and  even  '45 — 
the  latter  coincident  with  a  wild  maniacal  outburst. 


Amouxt  of  H^moglobix  IX  THE  Blood  in 

THE   SUB-TECTS  OF  PuERPERAL  LvSANITY. 

d 

o  c 
|l 

0-"  O 

o  o 

IS  5 

c  o 

2  s 
B  c< 

^0 

Bemases. 

M.  A.  M.,  (Oct.  1,  '87), 

(Oct.  4,  '87), 
(Oct.  8,  '87), 
(Nov.  6,  '87), 

M.  A.  P.,   (Nov.  15,  '87), 

H.  S.  L., .  (Nov.  2,  '87), 
C.  C,  .     .  (Dec.  2,  '87), 
R.  W.  J.,  (Aug.  10,  '89), 

20 

28 
24 
32 

74 

78 
60 
55 

53-6 

41-4 
40-8 
71-6 

93-6 

102-8 
80-6 
124 

•25 

•06 
•12 
•16 

•28 

•22 

•24 
•IS 

•35 

•68 
•60 
•45 

•79 

•70 
•75 
•44 

Extreme  waxy  pallor:  blood  rert/pa'e,  watery, 
and  instantly  separates  into  serum  on 
withdrawal; "contains  many  minute  cells 
like  nuclei  and  ill-formed  corpuscles. 

Minute  fat  jrlobules  in  the  blood  and  many 
ill-formed  corpuscles. 

Still  many  minute  nuclear  bodies;  blood  pale 
but  has  more  consistence. 

Red  discs  all  contain  minute  glistening 
nuclear  bodies;  some  tend  to  form  dumb- 
bell shapes  and  readily  split  up.  iVild 
excitement  for  some  davf  past. 

Profound  melancholia;  waxy  pallor  of  face; 
compulsory  feeding  requisite.  Many 
minute  corpuscles  in  the  blood,  some  of 
dumb-bell  form;  larger  corpuscles  mea- 
sure C  to  S^i;  smaller  measure  Su. 

Considerable  torpor  of  movement;  much 
stupor  but  no  cataleptic  phenomena; 
pupils  dilateii ;  betrays  but  slight  antcmia. 

Medium  size  corpuscles  (5/^):  a  few  small 
nuclei  ('2  /j.)  ;  white  corpuscles  measure 
S^i.. 

*  Assuming  normal  blood  to  be  correctly  computed  at  5,000,000  per  cubic  millimetre. 


PROGNOSIS — PROTRACTED   RECOVERIES.  371 

Prog'nosis. — Of  the  seventy  cases,  fully  fifty-six  completely  re- 
covered at  the  asylum,  whilst  four  others  were  discharged  "relieved" 
— hence  the  recovery-rate  reached  the  favourable  pei'centage  of  80. 
The  mortality  was  8*5  per  cent,  of  the  whole  sixty-eight  cases — i.e.,  six 
died.  On  the  other  hand,  four  patients  (5-7  per  cent.)  still  remain  in 
the  asylum  as  chronic  incurable  cases  of  several  years'  standing.  On- 
consulting  the  recovery-chart  it  is  observed  that,  up  to  the  second 
month,  but  nine  cases  recover ;  thence,  up  to  the  sixth  month,  the 
recovei-ies  rise  gradually  to  an  aggregate  of  thirty-seven;  during  the 
following  two  months,  but  five  cases  recover;  at  the  ninth  month  there 
is  a  sudden  rise  in  the  recoveries,  from  which  period,  up  to  two  years- 
and  a-half,  a  few  casual  recoveries  are  still  noted.  The  recovery-rate 
does  not,  therefore,  contrast  so  favoui-ably  as  appears  in  Dr.  Clouston's 
statistics,  in  which  it  is  stated  that  in  three  months  over  half  had 
recovered,  and  in  nine  months  90  per  cent,  were  well.  Our  own  results 
show  that  rather  more  than  one-half  of  the  recoveries  occurred  by  the 
fifth  month,  and  an  advance  of  the  number  of  recoveries  to  forty-four 
by  the  end  of  the  sixth  month;  whilst,  as  in  Dr.  Clouston's  cases,  87-5 
per  cent,  had  recovered  by  the  ninth  month  from  the  commencement 
of  their  insanity. 

The  incalculable  advantage  of  early  treatment  is  very  obvious  in  the 
recovery-list;  since  of  four-and-twenty  who  were  placed  in  the  asylum 
within  one  week  of  the  onset  of  their  insanity,  as  many  as  thirteen 
were  recovered  within  three  months,  and  the  remaining  eleven  left 
recovered  within  five  months,  and  this  despite  the  fact  that  several  of 
these  patients  had  inherited  strong  neurotic  tendencies;  thus,  the 
family  records  of  these  twenty-four  (early)  recoveries  testify  to  the- 
following  facts : — 

Mother  paralysed,  ..... 

Brother  insane,       .         .         .         .         . 

Mother  insane,        .         .         .         .       "j 

Sister  insane ;  father  a  heavy  drinker,  / 
Sister  insane,  ...... 

Grandfather  insane  and  committed  suicide,    . 
Father  insane,         ...... 

Father  and  mother  insane  (second  attack), 
Aunt  and  two  cousins  insane  (second  attack), 
Aunt  insane,  ....... 

Even  direct  inheritance  does  not,  therefore,  seem  so  sti'ongly  to  aflect 
the  recovery-rate  in  such  cases  when  placed  at  an  early  date  undei- 
suitable  treatment. 

Let  us  now  turn  from  the  favourable  cases  to  those  in  which 
recovery  was  protracted  to  six  months  and  later.  It  becomes  a 
significant  fact  that  these  are  cases  where  asylum  treatment  has  beea 


Recovery 

ill  2^ 

months 

5 

5i 

2 
1 

4| 

OJ. 

4 

372 


INSANITY    AT    THE    PUKUPKHAL    PERIOD. 


deferred,  and  the  patient  kept  under  their  friends'  supervision  for  a 
period  ranging  from  two  weeks  to  several  months. 


Case. 

Onset  prior  to 
Asylum  '1  reatincnt. 

1 

4  wenks    . 

2      „      (brotlie 

4 

3           M 

5 

4      ,,        . 

G 

3     „        .         . 

/ 

9 

S 

6  months 

9 

7             !) 

10 

•7 

11 

3      „ 

12 

3      „ 

13 

2 

14 

3  weeks   . 

15 

2      ,,        .         . 

16 

3  months 

17 

2      ,, 

IS 

? 

19 

7  weeks    . 

20 

7      ,,        .         . 

21 

9      ,,      (paterL 

22 

.         2      „      (      „ 

23 

4  months 

24 

■         1       „ 

25 

.       25      ,, 

Recovered. 

Age. 

7    months 

26 

7         1, 

36 

'         1) 

22 

7i       „ 

25 

9 

24 

9 

24 

25 

94       „ 

48 

9 

38 

9 

21 

10         „ 

24 

11         „ 

27 

Hi     „ 

25 

!•- 

29 

i3i       „ 

22 

1-1         „ 

27 

2    J'ears 

27 

-a       )) 

24 

Gj  months 

25 

.      H     „ 

22 

ty) 

H     „ 

26 

) 

6i       „ 

28 

G 

28 

6 

24 

Oi       „ 

25 

Equally  instructive  is  it  to  note,  that  the  failures  amongst  those  who 
were  but  partially  relieved  and  so  discharged,  or  who  remained,  as 
chronic  insane,  or  who  succumbed  to  a  fatal  malady  were,  with  very 
few  exceptions,  either  late  admissions  or  over  thirty  years  of  age.  A 
glance  at  the  following  three  tables  illustrates  this  point  in  a  very 
forcible  manner : — 

MOKTAUTV. 

Date  and  Cause  of  Death, 
in  11  montlis;  of  tubercle, 
in    6|  years ;  of  phthisis, 
in    14  years ;  of  general  paralysis, 
in    1  month ;  of  pneumonia, 
in    3  months ;  of  phthisis, 
in    2  years  7  months;  of  general  paralysis, 
in    1  month;  of  pelvic  cellulitis, 
in    2  weeks;  of  chronic  brain  atrophy, 
in    1  week ;  of  pulmonary  congestion, 
in    4  months;  of  acute  cercbritis 
(father  and  mother  insane). 
10  days,  .         .        22        .         in    4  years ;  of  phthisis. 


Duration  of  Attack 
on  Admission. 

Age  of 
Patient. 

3  months, 

27 

3        „ 

38 

Several  months. 

42 

7  months, 

40 

1 

21 

11        „ 

28 

1  week, 

30 

1      ,. 

36 

1      » 

40 

1      „ 

35 

PROGNOSTIC    INDICATIONS — TREATMENT.                                 3/3 

Discharged  "Relieved." 

urntion  of  Attac 

Ic               Age  of 

on  Admission. 

Patient. 

Date  of  Discharge. 

2  weeks, 

30 

2  years. 

3  months, 

29 

6  months. 

5  weeks. 

39 

2  years  and  4  months. 

7  months,     . 

38 

2  months  (father  and  brother  insane). 

Sevei-al  months,   .         32 

84  months. 

Remaining 

'Chronic  Insane." 

8  weeks, 

34 

7  years ;  still  an  inmate. 

6     „ 

26 

7     ,,                    ,,              strong  heredity 

8  months, 

39 

1  year  and  8  mouths. 

1  week, 

30 

4  years. 

1     „ 

28 

5     „ 

In  conclusion,  tlien.  it  may  be  stated  that  the  insanity  occurring  at 
the  puerperal  period  is  one  of  most  acuts  character,  yet  most  faVOUP- 
ablG  as  regards  the  ultimate  issue  of  treatment. 

The  prognosis  will  be  influenced  more  especially  by — 

(a.)  Duration  of  the  symptoms  when  the  patient  is  brought  under 
treatment,  and 

(b.)  Largely  by  the  age  of  the  patient. 

If  the  patient  be  under  thirty,  and  judicious  treatment  be  employed 
within  a  week  of  the  onset,  the  prognosis  is  favourable;  every  day's 
delay  after  this  adds  to  the  ultimate  risk. 

If  the  patient  be  over  thirty  years  of  age,  and,  more  especially,  if 
the  treatment  has  been  delayed  for  two  weeks  or  longer,  then  the 
recovery  if  ensured  will  pi-obably  be  prolonged,  yet  the  risks  of  i^artial 
recovery  only  will  be  strengthened. 

Treatment. — Our  first  enquiries  should  be  directed  towards  the 
genito-urinary  system,  with  the  object  of  discovering  any  local  uterine 
mischief,  whether  tenderness  upon  palpation,  a  rising  temperature,  a 
history  of  arrested  or  foetid  lochia,  indicate  lurking  troubles  consequent 
upon  labour.-  The  most  careful  examination  should  be  made  with  the 
object  of  ascertaining  any  source  of  peripheral  excitation  which  may  be 
removable  or  palliated.  A  slight  pyrexial  movement  will  generally  be 
found  in  the  acute  maniacal  attacks  following  immediately  upon  partu- 
rition. It  is  always  advisable  to  begin  our  treatment  with  a  saline 
aperient,  and  secure  a  free  evacuation  of  the  bowel;  the  condition  of 
the  breasts  may  also  merit  attention.  A  bland  but  nutritive  and  fluid 
or  semi-fluid  food  (including  milk,  beef-tea,  broths,  and  eggs)  should  then 
be  given  at  very  regular  intervals — forcible  feeding  being  resorted  to 
should  the  exigencies  of  the  case  demand  it,  and,  in  fact,  this  is  usually 
the  rule.     The  condition  of  the  blood  would  appear  to  indicate  tjie 


374  INSANITY    AT   THE   GESTATION    PERIOD. 

administration  of  iron;  but,  in  all  these  cases  of  acute  excitement,  it  is 
well  not  to  give  chalybeate  preparations  until  a  much  later  date  in  the 
history  of  the  case  ;  at  all  events,  not  until  the  patient  takes  food  spon- 
taneously and  sleeps  fairly  well,  without  having  recourse  to  sedatives. 

The  form  of  sedative  and  soporific  is  of  importance ;  bromide  salts 
are  of  less  avail  singly  than  in  combination  with  chloral.  The  latter 
is  the  better  drug  to  rely  on  in  obstinate  insomnia.  Paraldehyd  has 
been  given  with  considerable  success,  and  is  certainly  more  ethcacious 
than  sulphonal ;  Itut,  of  the  three,  we  give  the  preference  to  chloral. 
Later  on,  with  abatement  of  maniacal  symptoms,  it  will  be  well  to 
administer  phosphatic  foods,  the  syrup  of  the  phosphates,  or  a  mixture 
of  the  ammonio-citrate  of  iron  along  with  malt  extract. 

In  later  stages,  the  question  of  uterine  involution  is  one  of  much 
moment — undoubtedly  a  defective  involution  has  much  to  do  with  the 
persistent  excitement  of  these  cases.  Here  Easton's  syrup,  the  liquor 
strychnife,  or  tincture  of  nux  vomica,  may  be  of  avail ;  or  the  chloride 
of  ammonium  may  be  given  with  advantage. 

Early  association  with  the  insane  should  be  avoided,  as  likely  to 
increase  the  irritative  process  going  on.  The  subject  should  be  kept 
at  first  confined  to  her  bed,  attended  by  a  nurse,  and  only  when  the 
maniacal  excitement  is  somewhat  abated  should  she  be  taken  into  the 
■open  air  for  short  walks,  or  allowed  to  associate  with  others  similarly 
deranged.  Warm  baths  may  be  utilised  with  advantage  dviring  the 
progress  of  the  case,  and  by  their  aid  it  is  possible  to  ensure  sleep  in 
many  cases  without  resorting  to  the  employment  of  sedatives. 

Insanity  of  Ppeg"nancy. — Insanity  during  the  period  of  gestation 
is  i^emarkable  for  the  infrequency  of  its  occurrence ;  upon  this  point 
all  authorities  are  agreed.  Our  statistics  in  lai-ge  pauper-asylums 
■certainly  corroborate  this  statement,  and,  when  we  deduct  the  cases 
admitted  subsequent  to  confinement,  but  whose  mental  ailment  de- 
finitely dates  from  a  period  prior  to  pai'tui'ition  and  only  estimate 
those  who  were  enceinte  on  admission,  we  reduce  the  numbers 
so  far  that  they  are  of  little  or  no  value  for  statistical  purposes. 
Eleven  cases  of  insanity  occurring  dux'ing  gestation  were  admitted 
amongst  a  total  of  1,814  female  admissions,  or  the  very  low  proportion 
of  0"6  per  cent.  ;  hence  our  experience  with  respect  to  insanity  at  this 
physiological  cycle  is  indeed  greatly  restricted.  So  great  is  the  repug- 
nance to  the  admission  of  such  cases,  and  very  naturally  so,  that 
undoubtedly  many  subjects  escape  asylum  supervision,  and  are  nursed 
through  transient  attacks  of  alienation  under  the  guardianship  of 
their  friends  at  home  ;  and,  on  the  other  hand,  so  frequent  are  the 
trifling  mental  ailments  of  the  earlier  mouths  of  ])regnancy — the 
juorbid  cravings,  the  emotional  and  moral  perversions — that  they  are 


SYMPTOMS — COURSE    AND    TERMINATION.  375 

regardetl  with  little  concern  ;  whilst  a  more  serious  mental  ailment 
may  be  excused  as  but  an  exaggerated  expression  of  the  same  states. 
Our  very  limited  experience  at  the  West  E,iding  Asylum  would  indi- 
cate that  insanity  at  this  period  is  by  no  means  more  prevalent  amongst 
jrrimiparce,  for  nine  of  the  eleven  cases  had  previously  borne  children, 
and  in  none  of  these  cases  had  the  patient  suffered  from  a  previous 
attack  of  insanity.  Cases  have  been  recorded  where  every  confinement 
has  been  preceded  by  mental  disturbance  amounting  to  genuine  in- 
sanity;  but  it  is  much  moi'e  usual  to  find  such  frequent  recurrence 
as  the  sequel  to  successive  parturitions,  than  in  the  pregnant  periods 
of  a  woman's  life. 

There  is  usually  a  period  of  mild  depression  for  some  time  observed 
ere  the  more  acute  outbreak  of  symptoms  ;  nervous  timidity  is  a 
frequent  accompaniment ;  the  patient  loses  confidence  in  herself,  and 
di'eads  that  some  imaginary  evil  is  about  to  befall  her;  she  becomes 
suspicious,  and  often  exhibits  want  of  confidence  in  her  husband  and 
i-elatives.  All  the  cases  which  required  removal  to  the  asylum  were 
fully-developed  forms  of  the  disease,  and,  without  exception,  were 
instances  of  acute  maniacal  excitement ;  they  were  not  associated  with 
expansive  emotional  states,  but  the  reverse.  Distrust,  timidity  were 
apparent  in  all ;  and,  at  times,  terror  induced  by  acute  hallucinations 
culminated  in  frequent  frenzied  excitement  and  the  wildest  conduct. 
Periods  of  sullen  reserve  would  alternate  with  sudden  outbursts  of 
mania  ;  and  the  subject  was  usually  watchful,  intensely  suspicious,  and 
suddenly  aggressive.  There  was  in  most  of  the  cases  a  special  danger 
of  suicidal  acts,  attempted  usually  under  the  influence  of  some  terrible 
delusion  ;  as  in  the  case  of  one  patient  who  believed  herself  seized  by 
Satan,  and  who  made  frantic  efibrts  to  leap  through  a  window.  The 
excitement  is  accompanied  by  great  incoherence ;  but  their  ramblings 
usually  betray  the  dominant  feelings  in  frequent  reference  to  blood- 
shed, murder,  treachery,  or  the  like.  The  most  persistent  insomnia 
often  prevails,  and  destructive  tendencies  are  at  first  obvious.  Later 
on  the  patient  may  have  alternations  of  depression  and  mild  excite- 
ment ;  in  which  she  is  flighty,  meddlesome,  treacherous,  and  prone  to 
vicious  conduct. 

The  larger  proportion  of  cases  occurred  heyond  the  third  month  of 
gestation,  and  two  cases  alone  left  the  asylum  recovered  before  their 
confinement.  The  proportion  of  "  recoveries  "  amounted  to  54*5  per 
cent.,  whilst  two  others  left,  after  a  prolonged  residence,  sufiiciently 
relieved  for  home  treatment ;  two,  however,  died — one  from  puerperal 
fever,  and  the  other  of  chronic  plithisis. 

With  respect  to  the  origin  of  the  mental  derangement  we  can  pre- 
dicate but  little  from  the  scanty  figures  at  our  disposal  and  the  history 


376  INSANITY    AT   THE    PKRIOD    OF    LACTATION. 

of  tLe  few  instances  afforded  us.  It  was  ascertained,  however,  that 
strong  hereditary  jn'edisposition  prevailed  in  3G  per  cent. ;  that  two  other 
cases  subsequently  died  of  general  paralysis ;  and  that  three  others, 
although  afibrding  no  history  of  ancestral  insanity,  were  considered 
to  be  of  comjenitally-defective  mental  organisation. 


INSANITY  AT  THE   PERIOD   OF   LACTATION. 

Contents. — Eisks  Attendant  ni>on  Lactation — Period  of  Uterine  Invohition — Period 
of  Mammai-y  Excitation — Symjitoms — Depressing  Uehisions — Impulsive  Nature 
(M.  W.) — Suicide  (M.  D.) — Case  of  E.  E.  C. — Intensity  of  Maniacal  Excitement 
— Sexual  Perversions — Hallucinations — Etiology — Exhaustion  and  the  Se(iuela; 
of  Labour — Protracted  Uterine  Involution — Lactation  during  Profound  Anaemia 
— Hyperlactation — Qualilications  of  the  Nursing  Mother — Period  for  Weaning 
— Prognosis — Treatment. 

To  a  certain  proportion  of  the  puerperal,  the  whole  period  of  lacta- 
tion is  one  fraught  with  risks.  The  period  is  one  of  acknowledged 
susceptibility,  and  when  conjoined  to  this  normal  exaltation  "we  have 
the  predisposition  engendered  by  ancestral  insanity,  the  acquired 
elements  evolved  out  of  vicious  modes  of  life,  and  inattention  to  the 
plainest  physiological  dicta,  the  moi'bid  impetus  towards  insanity  is 
greatly  strengthened.  Undoubtedly,  the  factors  peculiar  to  this  period 
of  lactation,  to  which  are  attributable  in  part  the  mental  reductions, 
vary  with  the  physiological  changes  incident  to  this  period.  Thus, 
in  the  earlier  period  of  lactation,  the  immediate  effects  of  gestation 
and  parturition,  or  the  changes  normally  aroused  in  the  uterus  on  the 
completion  of  labour,  are  of  paramount  importance  in  our  estimate  of 
the  origin  of  the  mental  ailment ;  and  so,  throughout  the  period  of 
uterine  involution,  the  reflex  irritation  from  the  ovario-uterine  ap- 
paratus is  of  primary  importance.  As,  however,  uterine  involution 
becomes  complete,  so  the  activity  of  the  mammary  secretion  assumes 
an  increasing  importance  in  its  effects  upon  the  economy  ;  in  lieu  of 
reflex  excitations  from  the  uterine  surface,  or  of  the  faults  arising  from 
defective  depuration,  the  nutrition  of  the  nerve-centres  becomes  more 
directly  involved. 

To  attempt,  however,  to  distinguish  betwixt  the  insanity  incident 
to  these  periods  as  distinct  nosological  entities  would  be  highly 
inconsistent,  and  not  justified  by  .a  scientific  estimate  of  the  relative 
value  of  symptomatic  indications.  The  insanity  of  the  partiirient  and 
early  puerperal  stage  imperceptibly  glides  into  that  which  characterises 
the  later  stages  of  lactation  ;  and  none  but  an  arbitrary  division  can 
be  assigned  (for  convenience  in  study)  as  the  termination  of  uterine 
involution.     Then,  again,  the  completion  of  involution  is  an  uncertain 


PREDOMINANCE    OF    MANIA    -WITn    DELUSIONS.  377 

poriod,  vai-ionsly  assigned  by  diflcrcnt  authorities.  One  month  is 
given  as  the  term  in  healthy  subjects,  under  good  hygienic  sur- 
roundings ;  six  weeks  is  the  accepted  time  in  continental  Lying-in 
Hospitals  {Barnes'*) ;  whilst  Tylor  Smithf  quotes  tioo  or  even  three 
months  as  the  probable  period.  We  may,  however,  accept  six  weeks 
after  parturition  as  the  period  when  the  uterus  and  ovaries  are  passing 
into  the  quiescent  stage,  during  which  lactation  assumes  its  own 
important  rule.  It  is  highly  essential  that  we  should  clearly  recognise 
this  overlapping  of  physiological  stages,  as  thereby  are  explained 
certain  exceptional  cases  which  occur  about  the  transition-period  here 
alluded  to. 

Symptoms. — The  prevailing  condition  at  this  period  is,  in  fact,  that 
of  an  acute  j)sychosis,  in  which  excitement  predominates,  and  in  which 
terrifying  hallucinations  (visual  and  aural,  or  combinations  of  these) 
lead-up  to  various  delusional  notions,  and  in  which  suspicion  of  friends, 
relatives,  and  neighbours  is  prominent;  fears  of  supernatural  agency 
are  not  infrequent,  strange  phantasms  haunt  the  eye,  mysterious 
whisperings,  unexplained  sounds,  or  more  definite  A^oices  issue  in  the 
moi'bid  imagery  of  angels  or  ministers  of  darkness.  The  loss  of  self- 
confidence  begets  the  frequent  notion  that  the  "soul  is  lost,"  or  that  all 
future  good  is  sacrificed  by  some  imagined  crimes  committed.  The 
moral  being  has  its  ultimate  foundations  shaken,  and  confidence  is  lost 
even  in  those  who  should  be  nearest  and  dearest  to  the  afilicted  one; 
the  husband's  fidelity  is  openly  challenged;  intrigues  of  acquaintances 
dreaded;  the  food  declared  to  be  poisoned. 

The  0nS6t  may  be  sudden;  it  is  far  more  frequently  preceded  by 
mild  depression.  The  patient  becomes  restless,  irritable,  variable  in 
mood,  suspicious  of  her  friends,  impatient  and  fretful;  she  is  apt  to 
misinterpret  the  conduct,  gestures,  and  words  of  others.  Then  come 
fitful  outbursts  of  anger,  extravagant  accusations,  or  actual  violence, 
and  the  onset  of  genuine  maniacal  symptoms.  Insomnia  usually 
prevails;  noisy,  boisterous,  incoherent  ramblings  ensue,  in  which  the 
patient  gives  utterance  to  fragmentary  sentences  from  which  we  glean 
the  condition  of  mind  to  be  one  of  distrust,  suspicion,  or  terror,  or  to 
be  dominated  by  aural  hallucinations. 

Tlie  delusional  notions  vary  from  time  to  time,  and  periods  of 
exaltation  alternate  with  mental  })ain,  rising  even  to  the  pitch  of  acute 
melancholia.  Such  subjects  usually  come  under  our  notice  in  asylums, 
looking  exceedingly  pallid  from  anpemia,  reduced,  thin,  and  jaded  from 
continued  sleeplessness  and  excitement.  In  this  stage  of  excitement 
they  are    often    dangerously   impulsive,    and   require    most   careful 

*  Diseases  of  Women,  p.  469.  +  Manual  of  Ohdetrics,  p.  92. 


378  INSANITY  AT  THE  PERIOD  OF  LACTATION. 

watching.  Thus,  one  of  oiu'  patients,  wlio  had  suckled  her  infant  up 
to  the  twelfth  month,  althou;rh  much  enfeebled  in  health,  became 
suddenly  maniacal  at  home;  she  struck  her  husband  on  the  head  with 
a  poker,  ran  a  darning-needle  into  his  side,  and  eventually  got  possession 
of  a  knife  at  night  and  gashed  his  throat  ere  she  could  be  secured. 

M.  W.,  aged  thirty-nine,  married,  and  the  mother  of  three  cliildren.  Patient  in- 
herited insanity  from  the  mother,  who  was  an  inmate  of  this  asylum  twenty  years 
ago  after  confinement.  The  patient  was  confined  twelve  months  prior  to  admission, 
and  had  brought  the  infant  up  at  the  breast  until  four  months  since,  when  depres- 
sion first  supervened :  her  health  began  to  fail,  restlessness,  low  spirits,  suici<lal 
feelings,  and  the  delusions  that  her  soul  was  lost,  that  the  devil  was  in  her  house, 
and  that  all  lier  friends  had  become  her  enemies,  characterised  this  period.  She 
had  suffered  from  continued  insomnia.     Patient  had  been  of  temperate  habits. 

She  was  communicative  upon  admission,  and  discoursed  readily  upon  the  subject 
of  her  mental  ailments.  Ever  since  weaning  the  child  she  had  been  depressed, 
filled  with  morbid  fancies,  frequently  felt  tempted  to  injure  herself,  had  lost  all 
control,  and  (unless  closely  observed)  would  certainly  have  destroyed  herself.  Had 
foimd  her  memory  much  impaired  of  late,  and  this  had  troubled  her  greatly ;  she 
had  also  taken  a  deep-rooted  dislike  to  her  home,  because  she  fancied  that  a  friend 
■who  lived  opposite  was  constantly  watching  her.  Admitted  that  she  btlieved  her 
soul  to  be  lost,  and  felt  given-up  to  despair.  The  catamenia  had  l)een  regular  and 
normal  for  some  months.  Cod-liver  oil  emulsion  ordered,  and  a  mixture  containing 
iO  mins.  of  liq.  opii,  and  aromatic  sulphuric  acid  three  times  daily. 

From  this  date  she  made  a  steady  progressive  improvement,  although  restless  at 
nights,  and  suspicious  of  the  patients  with  whom  she  was  associated ;  she  was  much 
given  to  brooding  and  introspection,  but  recovered  sufficientlj'  to  employ  herself  in 
household  occupations  within  two  months  of  her  admission  to  the  asylum.  Then 
came  a  relapse  with  sudden  suicidal  impulse,  and  it  is  noted,  Xovember  '2nd — "This 
morning,  when  employed  in  the  chief  female  officer's  bedroom,  she  was  caught  in 
the  act  of  suspending  herself  to  the  bed-post  by  the  blind-cord.^' 

She  was  again  placed  xmder  opium  treatment,  which  had  been  discontinued  for  a 
time,  and  from  this  date  onwards  physical  and  mental  improvement  continued,  and 
she  was  discharged  recovered,  after  a  residence  of  eight  and  a-half  months. 

Another  young  girl  in  the  sixth  month  of  nursing  was  admitted  in 
a  state  of  rambling  incoherence,  fiighty,  erratic,  and  given  to  silly 
laughter ;  reduced  in  health,  and  anaemic,  with  a  htemic  bruit.  She 
violently  assaulted  her  mother,  and  nearly  succeeded  in  throttling 
her  father,  whose  identity  she  appears  to  have  mistaken. 

Others  make  equally  determined  attempts  upon  their  own  life,  as 
in  the  case  of  a  poor  weakly  woman,  who,  struggling  against  the  odds 
of  penury,  had  been  suckling  other  infants  besides  her  own  for  a 
period  of  twelve  months  with  bai'ely  a  subsistence  diet.  Upon 
admission  she  made  a  most  desperate  attempt  to  drown  herself  in  a 
bath  in  which  she  was  placed,  fiercely  struggling  with  the  nurse  in 
her  efforts  to  keep  her  head  under  water. 


SUICIDAL    AND    IMPULSIVE    TENDENCIES.  379 

M.  D.,  aged  thirty-two,  married,  and  the  mother  of  tliree  cliildren,  showed  her 
fii'st  symptoms  of  mental  alienation  four  weeks  prior  to  admission.  Four  months 
before  this  date  she  gave  birth  to  twins,  and  had  suckled  both  u[)  to  the  present  time. 
The  history  testifies  to  great  depression,  with  attacks  of  intense  and  prolonged 
excitement,  with  incoherent  raving,  and  violent  aggressive  conduct.  She  had 
frequently  threatened  to  take  her  own  life,  and  had  once  tried  to  cut  her  throat. 
The  family  liistory  was  defective,  but  an  aunt  is  stated  to  have  died  in  an  asylum. 
On  admission  (Oct.  18th)  she  was  low,  despondent,  aud  emotional;  querulous 
and  discontented.  She  conversed  readily  upon  the  subject  of  her  depression,  and 
narrated  how  she  had  felt  low  and  depressed,  even  back  to  the  early  months  of 
pregnancy,  when  she  used  to  visit  a  neighbour's  farm,  where  there  was  a  great 
black  dog ;  when  she  became  more  despondent  she  developed  the  delusion  that 
her  child  would  be  like  a  dog.  She  was  at  this  time  very  thin  and  delicate  ;  the 
complexion  anaemic  and  blanched,  the  eyes  sunken  with  dark  pigmented  areolae 
around.  The  breasts  were  swollen,  distended  with  secretion,  and  tender.  Oleum 
ricini  was  at  once  administered,  and  belladonna  liniment  applied  to  the  breasts. 
The  patient  was  ordered  full  extra  diet  and  chloral,  if  necessary,  at  night. 

A  week  later,  she  was  greatly  depressed  ;  stated  that  she  had  suffered  when  at 
home  from  impulses  to  kill  he)'  children,  but  denied  this  fact  to  the  doctor.  She 
now  regards  this  artifice  as  a  great  sin  for  which  she  cannot  be  forgiven. 

Nov.  1st.  —  Is  most  determinedly  suicidal,  aud  sleepless  at  night.  Last  night 
she  tore  up  her  sheet  and  attempted  strangulation,  and  this  morning  repeated  the 
attempt  with  her  apron-string.  Expresses  her  determination  to  die.  Tinct.  opii., 
mins.  XXX.,  ter  die. 

Hov.  27th. — To-day  attempted  to  swallow  a  needle,  which  became  impacted  in 
phaiynx,  and  was  removed  with  some  difficulty. 

Nov.  29th. — It  was  discovered  by  the  appearance  of  swelling  and  stiffness  of 
the  neck,  that  she  had  also  on  the  27th  inserted  a  darning-needle  there  ;  she  was 
(questioned  on  the  ^Doint,  aud  admitted  the  act.  There  was  no  mark  in  the  skin, 
Ijut  by  pressure  on  the  opposite  side  of  the  neck  a  prominence  could  be  felt  over 
the  left  sterno-mastoid  muscle,  just  in  front  of  the  external  jugular.  It  was  cut 
down  upon,  and  a  large  darning-needle  removed. 

Bee.  14th.  —  After  slight  improvement  has  again  become  desperately  suicidal; 
tries  to  choke  herself  by  anythmg  she  can  lay  hands  upon,  aud  constantly  seeks 
to  obtain  needles  by  stealth. 

Dec.  16th. — This  morning  a  sharp  projection  like  the  head  of  a  needle  was  felt 
beneath  the  skin  on  the  right  side  of  the  neck,  about  the  middle  of  the  sterno- 
mastoid.  An  unsucoessful  attempt  at  removal  was  made,  owing  to  her  desperate 
struggling  to  prevent  it.  On  the  26th  inst.,  the  prominence  was  again  felt,  and  a 
needle  an  inch  aud  a-half  in  length  removed.  She  is  still  greatly  depressed  and 
suicidal. 

Then  follows  an  account  of  peritonitis,  during  the  course  of  which  no  foreign 
body  was  detected  by  external  palpation  ;  but  the  patient  rapidly  succumbed  to 
the  attack,  and  died  on  the  14th  of  January.  A  post-mortem  examination  ex- 
hibited a  localised  peritonitis,  the  coils  of  small  intestine  being  matted  together  by 
a  considerable  amount  of  lymph  and  ^Durulent  material :  the  large  bowel  had 
escaped  implication.  Slight  ulcerative  points,  with  patches  of  intense  congestion, 
were  revealed  along  the  jejunum  and  duodenum,  behmd  which  was  a  purulent 
collection  in  whicli  a  needle  1  h  incli  long  lay  embedded.  Three  other  needles  were 
found  in  the  substance  of  the  mesentery,  and  one  in  the  tissues  of  the  neck  ;  none 
■were  present  in  the  stomach  or  intestine.  In  the  stomach  Avas  a  piece  of  charred 
wood,  3^  inches  in  length  by  about  1  in  thickness. 


380  INSANITY    AT   THE    PERIOD    OP    LACTATION. 

A  similarly  enfeebled,  exsanguine,  nursing  mother,  reduced  by  seven 
former  pregnancies  and  nursings  during  tlio  period  often  yeai's — the  first 
accompanied  by  puerperal  convulsions,  and  each  subsequent  jjuerperum 
followed  by  severe  headache  and  symptoms  of  exhaustion — still  persists 
in  nursing,  despite  four  months'  warning  of  steady  progressive  en- 
feeblement.  In  a  state  of  acute  melancholia  so  induced,  she  rushed 
off  one  morning  with  the  intention  of  throwincr  herself  into  the  river 
Nidd,  but  was  arrested  in  the  act  by  the  "sudden  remembrance  of  her 
child  at  home ; "  she  returned  home,  and  next  day  swallowed  a  large 
quantity  of  laudanum.* 

E.  E.  C,  aged  thirty-eight,  the  mother  of  seven  children,  the  youngest  an  infant 
at  the  breast  until  a  few  days  previous  to  her  admission,  when  it  was  weaned.  She 
became  morbidly  depressed  about  a  month  before ;  despite  which  fact  she  continued 
to  nurse  the  child.  Had  been  married  ten  years,  and  throughout  this  period  her 
health  had  been  very  delicate.  Seven  years  since,  whilst  pregnant,  she  is  stated 
to  have  had  several  convulsive  seizures,  which  had  not  recurred  since;  but  at  each 
subsequent  period  of  gestation  she  suffered  from  prolonged  and  severe  headaches. 
Her  health  had  been  steadily  deteriorating  during  the  last  three  or  four  months  of 
lactation.  She  inherited  a  strong  neurotic  temperament,  and  had  always  l^een 
excitable;  her  maternal  grandmother  was  unstable  and  melancholic,  and  patient's 
brother  was  insane.  The  morbid  depression  occurred  a  month  since,  with  a 
general  indifference  or  dislike  to  her  family  and  home;  she  expressed  decided 
aversion  to  her  husbaud,  and  accused  him  of  wishing  to  rid  himself  of  her.  A 
week  later  she  tried  to  drown  herself,  but  was  prevented  b}'  the  thought  of  her 
cliildren  at  home ;  she  then  attempted  to  poison  herself  with  laudanum,  and  the 
symptoms  became  very  acute;  she  declared  that  she  felt  herself  to  be  a  burden  to 
her  family,  and  was  determined  not  to  live ;  obstinately  refused  food,  and  struggled 
violently  against  any  interference,  so  that  upon  admission  she  was  found  severely 
bruised.  When  received  into  the  asylum  she  was  in  a  state  of  acute  melancholia, 
greatly  terrified  and  agitated,  struggled  violently,  clutching  at  all  who  approached 
her,  and  having  a  pained  but  vacant,  staring  aspect.  She  was  very  emaciated, 
blanched,  and  antemic.     Her  breasts  were  flaccid. 

The  treatment  adopted  was  a  full  nutritious  diet  of  eggs,  milk,  beef-tea,  with 
port  wine,  given  forcibly  (if  necessary)  by  funnel;  chloral  was  given  at  night  to 
combat  the  incessant  wakefulness,  and  the  catheter  had  to  be  freely  employed. 

The  agitation  was  extreme,  her  speech  quite  incoherent,  her  utterances  broken 
but  mdicative  of  suspicion  and  distrust ;  she  was  continuallj^  trying  to  get  out  of 
bed  and  crawl  under  it  to  conceal  herself.  Hy  the  end  of  the  week  she  slept  well, 
was  less  resistant  and  obstinate,  but  forced  alimentation  had  still  to  be  employed. 
Eleven  days  after  admission  she  was  somewhat  calmer,  and  told  the  medical  olficer 
he  was  a  "London  detective."  Great  torpor  of  the  bowels  continued  after  admis- 
sion. For  three  weeks  compulsory  feeding  had  to  be  carried  on,  and  for  a  con- 
siderable time  subsequent  to  this  it  required  much  tact  on  the  part  of  her  nurse  to 
induce  her  to  take  food.     In  two  months  there  was  some  improvement,  less  agita- 

*  The  suicidal  propensity  was  witnessed  in  31 'S  per  cent,  of  our  cases;  impulsive 
violence  to  others  in  59  per  cent.  The  subjects  of  puerperal  insanity  gave  the  lower 
estimate  of  25  per  cent,  and  47  per  cent,  respectively. 


ACUTE    MANIACAL    DELIRIUM.  381 

tion,  but  a  dazeil,  vacant,  dcraeutod  aspect;  she  still  ■would  not  converse,  and  her 
habits  were  utterly  negligent.  This  condition  was  maintained  for  five  months 
succeeding  her  admission,  but  steady  improvement  in  general  health  was  pro- 
ceeding; she  was  putting  on  flesh,  was  far  less  anaemic,  and  began  to  employ  her- 
self in  the  wards.  In  nine  mouths  she  was  discharged,  recovered ;  but  her  con- 
valescence really  dated  a  month  earlier,  she  having  had  an  attack  of  sub-acute 
rheumatism,  which  prevented  her  earlier  discharge. 

The  character  of  the  maniacal  state  is  especially  one  of  intensity. 
It  is  essentially  an  acute  mania  with  or  without  hallucinations ;  but, 
yefc,  it  is  distinguished  from  the  still  more  intense  excitement  of  the 
early  puerperal  alienation,  just  as  ordinary  acute  mania  is  distinguished 
from  the  furor  of  epilepsy.  The  jiuerperal  form  is  peculiarly  prone  to 
wild,  impulsive,  indiscriminate  conduct,  as  the  outcome  of  very  extreme 
reductions  ;  it  is  peculiarly  a  convulsive  affection,  as  in  epileptic  furor; 
hut  such  ])rofound  reductions  do  not  present  themselves  in  the  mania 
of  early  lactation.  Occasionally,  but  very  rarely,  acute  delirious 
mania  may  occur,  as  in  the  following  case  : — 

S.  M.,  aged  thirtj'-one,  married  twelve  months  ago,  and  delivered  of  her  first  child 
three  months  before  her  admission.  The  labour  had  been  natural,  but  her  health, 
previously  reduced,  had  become  progressively  worse,  and  she  had  been  wholly 
incapable  of  attending  to  any  household  duties.  Still  she  nursed  her  infant  at  the 
breast,  and  persisted  in  doing  so  until  four  days  ago,  when  sudden  and  intense 
maniacal  excitement  supervened.  No  predisposition  was  discoverable,  and  the 
family  history  was  avowed  to  be  free  from  insanity,  epilepsy,  or  apoplexy.  The 
parents  were  both  living  and  healthy.  There  was  no  moral  element  involved  in 
the  causation.  On  admission  she  was  found  considerably  reduced,  pale,  feeble, 
tremulous  ;  the  pupils  widely  dilated  ;  there  was  great  anaemia  ;  the  breasts  were 
considerably  distended.  She  was  in  a  state  of  the  wildest  excitement,  absolutely 
incoherent,  and  uttei'ly  oblivious  to  the  nature  of  her  surroundings.  No  rational 
or  even  coherent  reply  could  be  obtained  from  her,  but  she  occasionally  repeated 
a  word  she  had  heard  uttered  just  before.  She  was  almost  incessantly  restless, 
and  could  with  difficulty  be  kept  in  bed.  At  home  she  had  obtained  no  sleep,  and 
persistently  refused  food  since  her  attack.  Abimdant  strong  nourishment,  with 
extract  of  beef,  was  ordered,  and  half-drachm  doses  of  chloral  to  be  given  at 
bed-time. 

Fortunately,  she  took  her  food  readily,  and  the  first  draught  procured  her  a 
little  sleep.  For  four  days  she  continued  in  a  state  of  acute  delii'ious  mania,  quite 
incoherent,  and  extremely  prostrate,  the  tongue  dry  and  coated,  the  lips  covered 
with  sordes.  She  then  became  somewhat  calmer,  and  in  six  daj's  was  able  to  sit 
up  in  the  day-room,  being  fairly  quiet  and  manageable.  She  still  took  food 
readily,  the  tongue  became  clean  and  moist,  the  lips  free  from  sordes,  and  the 
general  health  improved  considerably.  Chloral  was  now  given  only  occasionally 
at  night;  all  critical  sjTnptoms  had  entirely  subsided.  One  month  after  admission 
there  is  noted — "Mild  excitement,  with  gentle,  rambling  incoherence,  and  aural 
hallucinations.  Chloral  at  night  wholly  suspended."  There  was  mild  maniacal 
excitement  for  the  following  two  months,  characterised  by  no  notable  symjjtoras. 
She  was  stated  to  be  erratic,  wilful,  pert,  and  idle,  but  steadily  improving  in 
bodily  health.     Amenorrhcea,  however,  existed,  and  she  was  consequent Ij'  ordered 


382  INSANITY    AT    THE    PERIOD    OF    LACTATION'. 

the  iron  and  aloes  pill  twice  daily.  It  was  not  until  six  months  had  elapsed  from 
lier  admission  that  the  catamenia  were  re-established,  after  which  the  patient's 
mental  symptoms  (which  consisteil  of  very  slight  excitement,  suspicion,  and  unrea- 
sonable irritaliility)  passed  oil'  entirelj',  and  in  a  few  weeks  she  left  recovered. 

Tlie  intensity  of  excitement  is  accompanied  in  these  cases  by  great 
incoherence  and  much  motor  agitation ;  but,  in  many  instances,  the 
patient  is  dominated  by  delusions,  is  reticent,  evasive,  suspicious, 
yet  watchful,  and  (as  already  alhrmed)  dangerously  impulsive. 

The  delusional  conceptions  are  strikingly  similar  to  those  found 
in  the  early  puerperal  weeks,  when,  as  we  have  seen,  the  idea  of 
eternal  punishment  of  the  lost  soul,  of  ruin  and  misfortune  to  self 
and  family,  of  persecution  at  the  hands  of  husband  or  neighbours,  are 
the  more  prevalent  perversions;  the  idea  of  poisoning  is  less  frequently 
expressed  in  the  insanity  of  the  puerperal  months  than  at  this  period. 

In.  a  small  minority  of  these  forms  of  alienation,  exalted  notions 
are  apparent.  They  are  usually  evolved  out  of  religious  conceptions, 
the  patient  falls  into  ecstatic  states,  clasps  her  hands  and  is  wrapt 
in  prayer,  or,  maybe,  believes  herself  to  be  Christ.  With  such 
religious  delusions,  however,  far  more  frequently  prevail  obscure 
notions  of  demoniacal  agency ;  the  black-art  or  witchcraft  is  by  no 
means  an  unfrequent  form  of  explanation  given.  Thus,  one  of  our 
patients  believed  herself  bewitched,  and  called  herself  the  "  scarlet 
■woman  of  Revelation ; "  another  believed  herself  and  husband  were 
bewitched  by  the  sorceries  of  her  neighbours,  whom  she  constantly 
saw  peeping  at  her  through  the  windows,  and  whose  voices  as 
constantly  intimidated  her ;  and  yet  another  accuses  her  neighbours 
of  entering  her  room,  "crossing  her  furniture,  and  so  putting  all 
things  wrong." 

The  sexual  condition,  if  not  apparent  in  a  directly-expressed 
delusion,  is  often  manifest  in  the  patient's  behaviour,  indelicacy, 
obscene  erotic  language  or  gesture  ;  but  sexual  delusions  and  hal- 
lucinations are  by  no  means  infrequent.  The  revulsion  to  husband 
and  children  often  promj^ts  to  violence ;  one  poor  woman  whose  case 
we  recall,  publicly  disowned  her  child,  and  then  attempted  to  smother 
it.  Of  sixty-six  cases  recorded  of  "  lactational  insanity,"  forty-six — 
i.e.,  69 -G  per  cent. — had  delusions. 

Hallucinations  of  the  special  senses  were  expressed  in  twenty-two 
(33-8  per  cent.)  of  our  cases;  and,  hence,  were  of  more  frequent 
occurrence  than  in  ordinary  puerperal  insanity.  Visual  and  aural  may 
occur  separately  or  conjointly;  but  the  prevalence  of  the  aural  was 
notably  greater  and  more  pronounced,  even  when  both  senses  were 
affected.  They  were  always  of  a  depressing  and  painful  nature ;  and 
many  of  the  delusional  notions  referred  to  were  based  thereupon. 


FORMS    OF    MENTAL    DERAXGEMEXT    ASSUMED. 


383 


Tlie  vivid  nature  of  such  creations,  the  enfeeljled  frame  of  the  patient, 
the  complete  loss  of  self-assiirance,  and  the  resulting  anguish  induced, 
produce  a  picture  which  strongly  enlists  our  sympathies,  and  is  painful 
to  witness.  Thus  one  of  our  patients  is  surrounded  by  spiritual  beings 
— angels — fiends — who  tell  her  that  her  soul  is  damned;  another  is 
tortured  by  abusive  epithets  continually  shouted  to  her  down  the 
chimney  ;  another  hears  the  baying  of  furious  dogs,  and  sees  her 
children  killed  before  her  eyes.  In  their  intrinsic  nature,  therefore^ 
these  hallucinations  are  similar  to  those  of  puerperal  insanity. 

Upon  analysing  the  various  forms  of  alienation  fi-om  which  our  sixty- 
six  cases  suffered,  we  find  them,  as  contrasted  with  the  puerperal 
cases,  distributed  as  folloAvs: — 


Forms  of  Mental  Ailment, 
Simple  mania,    ..... 
Acute        ,, 

Acute  delirious  mania, 
Mania  with  prominent  delusions, 
Eccurrent  mania,       .         ... 
Dementia  with  excitement, 
Simple  melancholia,  .... 
Acute  ,,  .... 

Melancholia  with  prominent  delusions, 
Melancholy  with  stupor,    . 
General  paralysis,      .... 
Congenital  mental  defect, 


Lactational.     Puerperal. 
6  7 


18 
1 

11 
3 
1 


31 


3 

17 

2 

1 

GO 


1 

14 

1 


69 


It  is  clearly  apparent,  then,  that  at  both  periods  excitement  pre- 
dominates over  depression,  and  a  larger  proportion  of  acute  maniacal 
attacks  characterise  the  puerperal  period.  On  the  other  hand,  acute 
depression  (melancholia  agitans)  is  rarely  met  with,  whilst  melancholy 
with  delusions  is  frequent  at  both  periods. 

Excitement  in  the  early  Months. — The  more  acute  forms  of 

excitement  prevail  within  the  first  three  months  foUoicing  parturition  ; 
and  the  delusions  of  persecution  and  associated  gloom  and  despondency 
of  melancholia,  predominate  where  mental  symptoms  first  betrayed 
themselves  six  months  or  more  after  labour.  Thus,  of  twenty-seven 
cases  where  alienation  occurred  within  the  first  six  months,  there  were 
eight  cases  of  melancholia  to  seventeen  of  mania ;  whereas,  in  twenty- 
seven  cases,  between  six  and  twelve  months  subsequent  to  labour,  there 
were  ten  of  depression  to  fourteen  of  excitement ;  and,  later  still — 
after  twelve  months — there  were  but  eleven  cases,  viz.,  seven  of  depre-s- 
sion  and  four  of  maniacal  excitement. 

Etiolog'y. — It  is  highly  conducive  to  the  correct  appreciation  of 
these  forms  of  mental  disturbance  that  we  keep  in  view  the  numerous 


384  INSANITY   AT   THE    PERIOD   OF    LACTATION. 

factors  which  may  operate  as  exciting  causes  of  the  attack  ;  we  are  not 
dealhiff  in  the  majority  of  our  cases  with  a  simple  agency,  such  as 
hyperlactation  ;  we  have  to  consider  not  only  the  peculiar  mental 
temperament  and  physique  of  the  nursing  mother,  but  also  the  series 
ot"  accidents  which  may  have  occurred  before,  at,  or  subsequent  to 
labour,  and  their  often  far-reaching  results  ;  we  have  to  bear  in  mind 
the  possible  divergence  from  normal  physiological  reversions  of  the 
ovario-uterine  system,  as  well  as  the  prolongation  of  suckling  beyond 
the  limits  which  the  mother's  health  will  stand,  the  deprivation  of 
food  which  penury  may  entail,  and  the  long  list  of  moral  agencies  which 
poverty  and  wretchedness  so  frequently  call  up.  Amongst  the  more 
important  of  this  category  of  causes  are  : — 

1.  Severe  protracted  labour  with  instrumental  delivery. 

2.  ^Qv'yows pod-partum  hemorrhage,  or  the  Hooding  occurring  before  or  during 

labour. 

3.  Protracted  or  arrested  uterine  involution. 

4.  Lactation  where  profound  anaemia  already  exists. 

5.  Lactation  continued  after  the  appearance  of  genuine  mental  alienation. 
G.   Hyperlactation. 

Exhaustion  and  Sequelae  of  Labour.— As  regards  the  first  two 

causes  (which  give  rise  more  frequently  to  mental  alienation  at  an 
earlier  period) — the  so-called  puerperal  insanity — it  is  but  what  we 
should  expect  that  the  attendant  exhaustion  or  anaemia,  if  it  does  not 
at  once  issue  in  mental  derangement,  will  so  result  if  the  tax  of  lacta- 
tion be  severe ;  and  as  illustrating  this  we  append  the  following  from 
the  prior  history  of  a  few  cases  of  insanity  during  lactation  occurring 
over  six  weeks  after  labour  : — 

Case  1.  Primi]iara,  labour  very  protracted  and  severe. 

,,    2.  Instrumental  delivery,  severe  po'it-partum  haemorrhage. 

,,    3.  Protracted  labour,  profuse  haemorrhage. 

,,    4.  Instrumental  delivery,  profuse  flooding,  phlegmasia. 

,,    5.  Very  severe  post-partuni  haemorrhage. 

, ,    G.  Severe  flooding  during  gestation,  menorrhagia  at  all  catamenial  periods, 

profound  auremia. 
,,    7.  Menorrhagia  at  all  monthly  periods;  profound  aniumia. 

In  the  foregoing  series,  it  will  be  observed,  one  case  alone  was  that 
of  a  primiparous  subject ;  and,  in  fact,  insanity  during  lactation  is 
infrequent  after  first  confinements.  In  the  insanity  occurring  at,  or 
shortly  following,  labour  {puerperal  insanity),  primipai'se  play  a  far 
more  important  part;  32-3  per  cent,  of  such  cases  being  first  confine- 
ments. The  insanity  occurring  during  lactation  presents  us  with  but 
IG'G  per  cent,  as  primiparous  subjects.* 

*  First  labours,  16'G  per  cent.  Third  labours,  22"7  per  cent. 

Second    ,,        13  6        ,,  Fourth    ,,        19 '6       ,, 


PROTRACTED    INVOLUTION — EXHAUSTION. 


385 


Uterine  Involution.- — Wo  have  strong  reasons  for  suspecting  that 
defective  utcriiie  involution  plays  a  most  important  role  in  the  earlier 
cases  of  lactational  insanity ;  and  it  is  to  this  cause  we  may  often 
attribute  the  preponderance  of  excitement  over  depression  in  the 
earlier  months  of  lactation.  The  reflex  nature  of  the  neurosis  closely 
ai)proximates  to  that  which  we  know  to  be  largely  dependent  upon 
the  direct  agency  of  a  gravid  or  parturient  uterus;  and  the  results  of 
treatment,  moreover,  directed  towards  this  condition,  warrant  us  in 
assuming  protracted  involution  as  being  a  large  factor  in  these  earlier 
weeks  of  lactation. 

Suckling"  in  a  stag-e  of  cerebral  exhaustion  is,  perhaps,  of 

all  causes  the  source  of  the  more  severe  and  prolonged  insanity  at  this 
])criod.  It  is  by  no  means  uncommon  to  find  mothers  suckling  their 
infiints  several  months  after  the  appearance  of  indubitable  indications 
of  profound  cerebral  derangement,  loss  of  memory  and  attention, 
morbid  feelings  and  desires,  hallucinations  of  sight  and  especially  of 
hearing,  complete  change  of  disposition — yet  the  infatuated  patient 
clings  to  the  habit,  and  will  say,  as  one  of  our  poor  patients  did  to  her 
medical  attendant — "  I  cannot  give  up  the  child,  but  it  will  drive  me 
mad."  We  need  only  glance  at  the  accompanying  table,  abstracted 
from  the  history  of  sixty-five  cases  of  insanity  during  lactation,  to 
have  enforced  on  our  minds  the  importance,  as  an  etiological  factor,  of 
such  vicious  persistence  despite  failing  vigour,  progressive  anaemia,  and 
even  well-marked  mental  disturbance. 


Case. 
]. 


9. 
10. 

11. 
12. 
13. 

14. 
15. 

10. 


Suckled  infant  nine  months,  and  for  two  or  three  weeks  indubitably  insane. 
, ,        infant  seven  months,  and  for  several  weeks  had  been  failing  in  health 
and  ailing  mentally. 

several  other  infants,  as  well  as  her  own,  during  the  year. 

infant  nine  months,  whilst  extremely  delicate  and  in  feeble  health. 

child  for  four  years,  and  had  always  indulged  in  prolonged  lactation. 

infant  four  months,  although  for  years  depressed  and  garrulous. 

infant  fifteen  months,  last  three  months  during  alienation. 

infant  eleven  months,   yet  peculiar  and  deranged  throughout  the 
whole  period  of  lactation, 

infant  nine  months,  yet  for  three  months  distinctly  deranged  in  mind. 

infant  ten  months;  several  urajmic  convulsions  three  months  after 
confinement. 

infant  four  months,  yet  has  been  insane  for  two  years. 

infant  ten  months;  in  very  feeble  health  and  deranged  of  late. 

infant,  whilst  becoming  for  four  months  past  steadily  and  progres- 
sively enfeebled  and  blanched  from  ana^nia. 

infant  nine  months  and  a-half,  although  for  three  months  deranged, 

infant  nine  months,  j'et  depressed  for  years. 

twins  four  months,  yet  for  one  month  deranged  in  mind. 

'2o 


38G  IXSANITT    AT    THE    PERIOD    OF    LACTATION'. 

Injudicious  nursing,  thei'cforc,  pl.ays  a  very  important  part  in  the 
causation  of  many  of  these  cases  of  insanity  ;  but  in  all  such  cases 
alike,  it  is  to  be  noted  that  cerebral  malnutrition  from  anremia,  whether 
induced  by  hyperlactatiou,  by  copious  haimorrfiages,  by  the  cachexy  of 
intercurrent  fevers,  by  phthisis,  or  causes  associated  with  semi-starva- 
tion, arouses  the  self-same  form  of  mental  anomaly. 

To  supply  the  wants  of  the  infant  with  a  food  sufficient  in  quantity 
and  of  proper  quality,  the  nutritive  processes  of  the  mother  and  tissue- 
metabolism  must  maintain  a  well-regulated  balance.  The  mammary 
secretion  requires  not  only  saccharine  and  fatty,  but  nitrogenous 
materials  in  certain  due  proportions,  and  this  demand  is  made  upon 
the  blood-current  of  the  gland.  The  relative  amount  of  circulating 
albumen  and  carbo-hydrates  in  the  blood  is  apt  to  be  powerfully  affected 
by  many  agencies,  apart  from  the  actual  amount  introduced  by  the  food. 
Should  the  respiratory  function  be  diminished  or  retarded,  as  by  living 
in  badly-ventilated,  overheated  rooms,  the  carbo-hydrates  must  accumu- 
late in  the  blood-current,  and  tend  to  be  deposited  more  largely  in  the 
tissue  ;  the  same  result  must  accrue  in  anaemic  states  where  the  oxygen- 
carriers — the  red  corpuscles,  lessened  in  numbers,  fail  to  oxidise  the 
hydrocai-bons  circulating  in  the  blood.  In  the  nursing-mother  the 
accumulation  of  hydrocarbon  thus  brought  about  must  issue,  more  or 
less,  in  a  relatively-increased  amount  of  fatty  matters  in  the  milk  (as, 
for  instance,  occurs  in  stall-fed  animals).  On  the  other  hand,  should 
frequent  exposure  to  cold  stimulate  the  respiratory  functions  and 
oxygenation  proceed  more  vigorously,  the  hydrocarbons  are  diminished 
and  the  protein-compounds  undergo  a  relative  increase,  so  that  the 
milk  contains  more  casein,  whilst  the  fats  decrease.  If  much  muscular 
exertion  be  demanded  the  protein  metabolism  increases  and  appears 
directly  to  affect  the  composition  of  the  milk,  increasing  its  casein.* 
The  same  result  occurs  in  anaemia ;  it  is  found  that  the  excretion  of 
urea  is  increased,  and  carbonic  acid  diminished;  in  other  words,  protein 
metabolism  is  increased  and  fat  metabolism  lessened.  It  is,  therefore, 
obvious  that  a  due  proportion  of  nitrogenous  and  hydrocarbonaceous 
constituents  in  the  blood,  regulated  by  a  rational  diet  and  by  the  nor- 
mal metabolic  changes  occurring  in  the  tissues,  is  an  all-important 
feature  in  healthy  lactation ;  yet  the  function  itself  may  be  pi'ofoundly 
disturbed  by  a  vicious  system  of  suckling.  Thus  frequent  application 
of  the  infant  to  the  breast  not  only  stimulates  the  secretion  of  milk, 
but  also  modifies  its  quality.  The  quantity  is  largely  augmented, 
and  the  milk  becomes  much  richer  in  casein ;  hence  a  serious  drain 

*  Thus  we  are  told  that  the  cattle  exposed  to  cold  and  much  muscular  exertion 
in  Switzerland  yield  a  very  small  quantity  of  butter,  but  an  vmusually  large  pro- 
portion of  cheese. — Carpenter's  Physiology,  p.  013. 


QUALIFICATIOXS    OF    THE    NURSING    MOTHER.  387 

from  the  albuminous  constituents  of  the  blood  is  occasioned  and  anocmia 
results.  In  the  nursing-mothei'  an  accumulation  of  storage-fat  appears 
to  occur,  reminding  one  of  the  condition  of  hyl^ernating  animals,  in 
which,  during  a  prolonged  winter's  sleep,  the  entire  absence  of  food 
requires  (despite  the  cessation  of  activity  and  the  extremely  lowered 
rcspii'atoiy  and  heat  processes)  a  large  storage  of  fat  to  supply  the  slow, 
though  continuous,  waste.  So  in  the  nurse,  the  waste  occurring  through 
the  mammaiy  secretion  appears  to  demand  a  fat-storage  both  for  the 
maintenance  of  such  a  secretion  and  the  respiratory  functions  ;  the  early 
months  of  lactation  are  consequently  roarked  by  the  plumpness  of  the 
body  generally — healthy  nursing  mothers  almost  invariably  "put  on 
fat"  at  this  time  of  life;  and  it  is  only  late  on  in  lactation,  when  the 
system  begins  to  appreciate  a  serious  drain,  that  the  rotundity  of  the 
figure  lessens  {Trousseau).  It  is  a  condition  of  serious  moment  when 
we  find  the  nurse  not  so  px'epared  for  her  arduous  functions,  and  it  is  a 
notable  fact  that,  in  a  very  large  proportion  of  cases  of  insanity  occur- 
ring during  lactation,  this  symptom  of  ominous  significance  is  recorded. 
It  should  always  be  accepted  as  a  note  of  warning  in  those  who  are 
predisposed  to  insanity,  or  who  have  afforded  evidence  of  cerebral 
malnutrition.  Such  failings  are  usually  due  to  injudicious  nursing ; 
and  injudicious  nursing  is  at  the  root  of  most  of  the  cases  of  aberration 
occurring  during  lactation.  It  is  not  so  much  jwolonged  lactation  as 
over-indulgence,  often  of  a  strong,  robust  infant,  whilst  the  nurse  is  in 
a  delicate  state  of  health.  If  we  consult  our  statistics  we  find  that, 
out  of  sixty-five  cases,  twenty-seven  had  suckled  but  six  months,  and 
twenty-seven  others  had  suckled  up  to  the  ninth  and  twelfth  months  ; 
obviously,  then,  protracted  suckling  had  not  so  much  to  do  with  the 
cause  as  other  factors. 

"What  occurs  is  this,  a  woman  in  delicate  health,  often  after 
numerous  rapidly  -  succeeding  confinements,  or  perhaps  after  a 
tedious  puerperum,  or,  maybe,  hremorrhage  before  or  during  labour, 
suckles  her  infant  with  injudicious  frequency,  saci-ifices  her  rest 
night  after  night,  and  probably  takes  insufficient  or  unsuitable 
nourishment.  The  constant  drain  from  her  system  and  loss  of  rest 
engender  antemic  and  dyspeptic  symptoms,  still  less  favouring  the 
restoration  of  the  material  lost  from  her  blood.  The  superficial  fat 
disappears  to  supply  the  demands  of  the  exhaustive  secretion.  The 
carbohydrates,  rapidly  diminished,  no  longer  can  exert  that  protective 
influence  over  protein  metabolism  (Landois  and  Stirling*),  and  a 
further  waste  occurs  in  this  direction — first,  the  circulating  albumen 
feels  the  drain,  and  later,  the  organised  albumen  must  still  further 

*  It  must  be  remembered  that  only  part  of  the  fat  is  derived  from  the  food 
dircctl}'- ;  the  rest  is  a  product  of  a  splitting-up  of  proteids  in  tissue  metabolism 
(Landois  and  Stirling's  Human  Physiology,  p.  518). 


388  INSANITY    AT   THE    PERIOD   OF    LACTATION. 

aid  in  the  formation  of  the  fatty  principles  required.*  In  this  way, 
as  in  all  cases  where  a  similar  drain  upon  the  system  occurs 
(leucorrhcea,  diarrhoja,  profuse  suppuration),  ansemia  of  profound 
character  supervenes ;  our  patient  comes  before  us  with  pallid  face, 
with  blanched  lips,  with  small  feeble  pulse,  the  heart's  muscle 
exhausted,  and  the  breathing  often  hurried  and  panting,  and  the 
muscles  of  the  limbs  flabby  and  ill-nourished ;  she  complains  of 
headache,  vertigo,  dimness  of  vision,  lassitude  and  aching  limbs.  In 
lieu  of  the  fresh-coloured  healthy  glow  of  the  cheeks,  the  plumpness 
and  firmness  of  tissue,  indicative  of  active  functionising  and 
vigorous  health,  the  normal  ebb  and  flow  of  lively  emotion,  and 
warm  interest  in  the  nursling,  which  characterise  the  good  efiicient 
nurse,  we  have  a  miserably  pallid  wasted  object,  half-starved,  queru- 
lous, full  of  imaginary  ailments,  tormenting  fears,  and  morbid  sus- 
picions. 

Despite  all  these  symptoms,  some  women  will  still  persist  in 
suckling  their  ofi"spring  from  misguided  maternal  instincts,  and  often 
with  the  object  of  deferring  a  subsequent  conception ;  the  hydrremic 
state  of  the  blood  results  in  a  slow  and  sluggish  circulation,  and  in 
the  splenic  pulp,  and  especially  the  portal  circulation  of  the  liver,t 
as  in  the  marrow  of  bone  such  sluggish  flow  favours  the  destructive 
hfemolytic  action  which  goes  on  here — the  red  corpuscles  are  rapidly 
disintegrated  {Quincke). 

Although  it  has  been  demonstrated  that  in  inanition,  the  central 
nervous-system  loses  in  weight  more  slowly  than  almost  all  tissues 
and  organs  (with  the  exception  of  the  spleen,  kidneys,  and  heart),  and 
incomparably  less  than  the  fat,  muscles,  and  even  bones  (see  V.  Yoit's 
experiments  quoted  by  Landois,  p.  514),  yet,  the  brain  is  undoubtedly 
the  organ  which  earliest  registers  any  disturbance  in  its  nutrition. 
This  is  what  we  might  expect ;  since,  being  the  custodian  of  all 
organic  impressions,  to  which  is  relegated  the  function  of  giving  the 
alarm  when  the  activity  of  other  organs  is  disturbed,  it  is  highly 
necessary  that  its  own  welfare  when  threatened  should  be  expressed 
with  no  uncertain  ciy. 

Wliat  is  the  pro2:ier  time  for  weaning  ?     The  period  is,  of  course,  a 

*  Then,  also,  M'e  must  remember  that  (as  Voit  shows),  although  in  ordinary 
health  a  large  amount  of  circulating  albumen  is  split -up,  whilst  the  organic 
albumen  of  the  organs  and  tissues  continues  comparatively  stable  ;  yet,  in  certain 
pathological  states,  the  organic  albumen  becoming  very  imstable  may  undergo 
rapid  disintegration,  as  in  fevers,  &c.     (Stirling,  op.  cit.,  vol.  i. ,  ji.  506). 

+  The  liver  is  regarded  as  one  of  the  chief  sites  of  haemolysis  "  because  bile- 
pigments  are  formed  from  hemoglobin,  and  the  blood  of  the  hepatic  vein  contains 
fewer  red  corpuscles  than  the  blood  of  the  portal  vein"  (Stirling,  op.  cit.,  vol.  i., 
p.  17). 


PERIOD    FOR   WEANING.  389 

most  variable  and  uncertain  time ;  eacli  individual  case  must  be 
judged  upon  its  own  merits,  and  in  considering,  as  we  are  compelled 
to  do,  tlie  interests  of  both  parties,  the  mother  and  offspring,  the 
question  necessarily  becomes  peculiarly  trying  and  delicate,  owing  to 
the  fact  that  the  immediate  interest  of  the  one  often  appears  antag- 
onistic to  that  of  the  other.  Ultimately  we  know  that,  if  the  nurse 
suckle  beyond  her  strength,  the  result  will  prove  highly  prejudicial 
to  both,  yet,  the  infant's  health  may  be  such  that  artificial  feeding  is 
inadmissible  and  urgently  demands  breast-milk  of  a  quantity  and 
quality  beyond  the  mother's  capability  to  supply.  Undoubtedly, 
natural  feeding  at  the  breast  should  be  adopted  in  all  cases  where  the 
health  of  the  nurse  is  not  seriously  imperilled,  and  when  the  breasts 
supply  a  due  amount  of  nourishment  for  the  infant's  wants ;  as, 
hereby,  the  well-being  of  both  is  best  secured ;  but,  when  the  lacteal 
secretion  is  scanty,  or  its  quality  such  as  to  render  it  unsuitable  in 
the  case  of  a  weakly  infant,  to  whom  artificial  feeding  might  prove  a 
greater  peril,  the  ,  balancing  of  odds  is  often  a  difficult  matter. 
Consistently  with  the  mother's  health,  every  effort  must  be  made  to 
bring  up  the  child  at  the  breast,  over  the  more  eventful  dentition 
crisis  through  which  it  has  to  pass,  and  this  might  be  oftener  done  by 
weakly  nurses  if  due  regard  were  paid  to  a  judicious  course  of 
suckling  and  avoidance  of  errors  so  notoriously  frequent. 

The  child  has  to  be  educated  into  a  regular  system  of  feeding  ;  and 
this  should  be  so  managed,  that  the  mother  may  secure  a  pi'olonged 
rest  and  sleep  at  night,  and  the  injurious  habit  avoided  of  indulging 
at  night  every  passionate  outcry  by  application  to  the  breast. 

The  rule  given  by  Trousseau  holds  good  for  most  cases  wdiere  we 
deal  with  a  healthy  nurse — viz.,  that  the  period  of  lactation  be 
extended  in  most  cases  over  the  period  of  evolution  of  the  canine 
teeth. 

"My  rule,  provided  there  be  no  serious  obstacles  to  surmount,  other  than  the 
wishes  of  the  family,  is  not  to  wean  the  child  until  after  the  complete  evolution 
of  the  canine  teeth,  which  is  generally  a  more  difficult  process  than  the  evolution 
of  the  incisors  or  first  molars.  My  rule,  therefore,  is  to  wait,  irrespective  of  age, 
till  the  infant  has  sixteen  teeth."* 

Of  course  any  such  rule  falls  short  in  its  application  to  cases  such 
as  we  are  now  considering.  The  welfare  of  the  mother,  if  of  neurotic 
inheritance,  and  exhibiting  emaciation  and  anaemia  in  the  early 
months  of  lactation,  is  so  greatly  threatened  as  to  demand  the 
immediate  cessation  of  nursing. 

Prognosis. — The  recovery-rate  appears  to  be  directly  affected  by 
the  date  subsequent  to  parturition  at  which  the  insanity  appears ;  the 

*  Trousseau,  op.  cit.,  vol.  iv.,  p.  163. 


390  INSANITY    AT   THE    PEIUOD   OF    LACTATION. 

earlier  the  symptoms  of  mental  alienation  occur,  the  more  favourahle  is 
the  issue  likely  to  be.  Hence,  the  recovery-rate  is  higher  for  puerperal 
cases — that  is,  cases  arising  within  six  weeks  of  confinement,  than  dur- 
ing later  lactation,  as  SO  per  cent,  is  to  65 -G  per  cent.  The  percentage 
of  recoveries  for  the  whole  number  of  female  cases  of  insanity  was  44-G, 
so  that  the  percentage  of  65*6  represents  a  very  favourable  rate  of 
recovery,  and  justifies  a  good  prognosis,  although  of  a  less  favourable 
nature  than  in  puerperal  insanity.     {Chart  C.) 

If  a  chart  of  recoveries  in  puerperal  and  lactational  forms  be  con- 
trasted, a  notable  uniformity  is  recognised  throughout,  the  largest 
number  of  recoveries  in  both  occurring  at  the  fifth  or  sixth  months 
and  rapidly  declining  in  the  subsequent  period.  At  the  ninth  month 
of  puerperal  females,  however,  a  remarkable  rise  again  occurs  in  the 
recoveries  of  seven  cases,  somewhat  paralleled  by  a  less  conspicuous 
rise  at  the  eighth  month  in  lactational  cases.  "Whatever  be  the  cause 
of  these  wave-like  recurrence  of  cases,  it  is  obvious  that  the  periods  at 
which  the  recoveries  chiefly  tend  to  occur  in  both  series  of  cases  are 
from  two  to  three,  from  five  to  six,  and,  again,  from  eight  to  nine 
months  from  the  onset  of  the  disease.  Age  exercises  less  apparent 
influence  upon  the  number  of  occurring  cases  than  upon  the  nature  of 
the  attack,  and  so  indirectly  aflecting  the  issue.  The  influence  of  age 
upon  insanity  occurring  during  suckling,  in  a  series  of  sixty -five  cases 
where  the  age  was  definitely  given,  may  be  illustrated  by  the  following 
table  : — 


Age. 

Kecovered. 

Eeaeved. 

^'^^-           Chronic. 

Tota 

om  15  to  20 

1 

(at  19) 

1 

„     20  to  25 

9 

2 

2 

13 

„     25  to  30 

15 

3 

1                  2 

21 

„     30  to  .35 

13 

1 

3                  3 

20 

„     35  to  40 

5 

1 

2                  1 

9 

„     40  to  45 

\(G.P.)     ... 

1 

43  7  9  0  65 

If  we  compute  as  failures  the  fatal  and  chronic  cases,  it  will  be 
observed  that  the  ratio  of  these  unfavourable  cases  steadily  augments 
towards  the  age  of  forty,  increasing  from  one-sixth  of  the  whole  at  the 
age  of  twenty,  to  one-third  at  the  age  of  forty.  The  large  proportion 
of  cases  of  insanity  appear  from  the  total  column  in  the  above  table  to 
have  occurred  between  the  ages  of  twenty-five  and  thirty-five.  We 
find,  moreover,  that  the  proportion  of  maniacal  to  depressed,  melan- 
cholic subjects  is  far  greater  at  the  earlier  age  of  twenty  to  twenty-five, 
and  progressively  lessens  until,  at  forty,  excitement  and  depression 
prevail  in  about  the  same  relative  frequency.     It  would  thus  apj^ear, 


L- 


CHARTof  RECOVERIES  m  70  PUERPERAL  4  67  LACTATION  CASES 


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1 

^t 

1 

l\ 

1 

H 

J 

I 

Ir 

\" 

I 

it 

1 

! 

i 

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I 

i. 

,/ 

'\ 

/ 

^1 

\ 

v 

1 

/ 

/ 

1 

N 

v^ 

ANALYSIS   OF  RESULTS. 

Recovered      Relieved        Died         Chrc 


PROGNOSIS — TUEATMENT.  391 

at  first  sight,  tliat  youth  is  favoured  as  regards  greater  immunity  from 
such  affections ;  in  the  attack  being  more  acute,  and  hence  more 
favourable ;  and  in  the  ultimate  issue  in  recovery.  Tliis  would  not, 
however,  express  the  case  truthfully,  since  the  proportion  of  married 
women  in  the  population  of  our  asylum-district  between  the  ages  of 
twenty  and  twenty-five  is  considerably  below  the  married  population 
of  the  following  decennial  period  of  life.  In  fact,  between  the  ages  of 
twenty-five  and  thirty-five,  the  population  is  nearly  122,000  as  against 
37,500  who  are  from  twenty  to  twenty-five  years  of  age;  this  represents 
a  ratio  of  3-2i6  to  1.  Taking,  therefore,  into  consideration  this  fact, 
that  the  number  of  married  women  in  the  West  Ptiding  between  the 
ages  of  twenty-five  and  thirty-five  is  more  than  trijde  that  of  the 
married  from  twenty  to  twenty-five  years  of  age,  it  is  seen  that  the 
younger  class  do  not  share  an  immunity  from  the  ills  attendant  on 
lactation;  the  incidence  of  insanity  at  these  ages  being  almost  identical. 
That  depression  prevails  in  the  later  quinquennials  and  that  \infavour- 
able  results  multiply  disproportionately  may  be  regarded  as  established, 
so  far  as  these  statistics  lead  us  to  infer.  A  fatal  issue  in  these  cases  of 
insanity  during  lactation  is  not  to  be  feared  apart  from  the  complication 
with  other  affections,  especially  the  phthisical  tendency,  which  is  prone 
to  declare  itself  at  this  epoch ;  more  than  half  the  deaths  were  due 
to  this  cause  in  our  own  statistics,  tAvo  others  issued  in  general 
paralysis,  and  the  remaining  fatal  case  was  one  of  suicide,  already 
recorded. 

Treatment.  — In  most  instances  our  patient's  bodily  condition  claims 
the  chief  attention ;  her  strength  must  be  nursed  and  supported  by 
every  possible  measure.  Should  the  breasts  be  tumid,  we  must  treat 
that  condition  by  the  employment  of  belladonna  inunctions,  by 
atropine  internally,  by  local  friction,  and  by  gentle  saline  laxatives. 
A  general  tonic  regimen  must  be  from  the  first  enforced.  The  food 
should  be  liberal,  nutritive,  and  easy  of  digestion;  for  errors,  diges- 
tive and  assimilative,  are  almost  of  constant  occurrence  in  such 
cases.  The  peptonised  and  pancreatised  preparations,  and  zymine 
in  intestinal  derangement,  may  be  utilised  with  advantage,  more 
especially  if  we  endeavour  to  associate  therewith  cod-liver  oil  and 
malt  extractives. 

Combinations  of  iron  with  arsenic,  or  with  other  mineral  nervine 
tonics,  are  especially  useful,  and  the  physical  improvement  so  induced 
is  usually  accompanied  by  a  decided  mental  reinstatement — dej)ression 
abates,  and  a  healthier  tone  prevails.  The  sulphate  of  iron,  in  com- 
bination with  aloetic  purgatives  as  a  pill,  is  a  useful  remedy  for  the 
constipation  associated  with  the  hepatic  and  intestinal  torpor  of  some 
of  these  cases ;  cascara  sagrada  may  also  be  given  here  with  advantage 


392  INSANITY    AT   THE    CLIMACTKRIC    EPOCH. 

alone,  or,  better  still,  in  combination  with  euonymin.  Shower-l)aths, 
cold  spinal  douches,  and  open-air  exercise  arc  applicable  in  most 
instances.  It  is  not,  as  a  rule,  advisable  to  adopt  sedative  treatment, 
except  in  the  more  intense  forms  of  depression,  when  morphia  given 
subcutanoously,  or  the  liquor  opii,  Avill  prove  the  more  useful  drugs ; 
"we  should  trust  far  more  to  general  hygienic  means  for  restoring  tone 
to  the  system,  improving  the  appetite,  and  the  digestive  and  assimi- 
lative powers,  and  for  inducing  sleep. 


INSANITY  AT  THE   CLIMACTERIC  EPOCH. 

Contents.^ — Symptoms — A  Subacute  Dehisional  Melancholia — Suicidal  Tendency 
(S.  H.) — Nymphomania  (A.  A.) — Etiology — Incidence  of  Insanity  at  diflerent 
ages  in  4085  cases — Influence  of  the  Climacteric — The  Psychological  Trans- 
formations of  this  Epoch— Instinctive  Actions — The  "  Time-de7nent"  in  Prog- 
nosis— Alcoholism  and  the  Climacteric — Treatment. 

Symptoms. — The  mental  ailment  most  frequent  at  this  period  in 
■women  is  an  affective  insanity,  in  which  gloom  and  despondency  are 
associated  with  paralysed  energies,  indecision,  and  volitional  inactivity ; 
a  condition  pertaining  to  melancholic  states  at  all  periods  of  life ;  yet, 
the  peculiar  character  of  the  psychosis  is  the  frequency  of  religious 
despondency,  and  delusions  respecting  the  moral  well-being  of  the 
subject.  The  sj^mptoms  grow  in  severity;  suicidal  feelings  become 
prevalent;  and  the  delusion  that  the  soul  is  lost  often  creates  fits  of 
mental  agony  or  despair.* 

At  its  early  evolution  painful  mental  states  invariably  prevail,  and 
in  over  55  per  cent,  of  our  cases  mental  depression  existed  throughout 
the  attack—  a  sub-acute  delusional  melancholia  being  far  the  more 
frequent  form ;  yet  maniacal  states  are  by  no  means  unfrequent,  and 
outbursts  of  excitement,  alternating  with  dejjression,  are  prone  to  occur 
at  a  later  stage  of  its  history.  Sensorial  anomalies  early  arise  and  are 
strangely  tinctured  by  the  prevailing  emotional  gloom.  The  spirit- 
world  is  the  subject-matter  of  her  broodings ;  mystic  communications 
are  received  from  above  announcing  her  hopeless  fate,  or  threatening 
terrible  judgments;  or  supernatural  agents  appear  visibly  and  terrify 
her  in  her  half-waking  moments.  Visual  and  aural  hallucinations 
occur  in  about  the  same  proportion  of  cases,  27  per  cent,  of  the  whole 
series  being  subject  to  such  anomalies ;  whilst  evidence  of  the  imjjli- 
cation  of  other  special  senses  was  very  rarely  obtained.     Intellectual 

*  Thus  Dr.  Skae  characterised  the  alienation  occurring  at  this  period  of  life  as: — 
"A  monomania  of  fear,  despondency,  remorse,  hopelessness,  passuig  occasionally 
into  dementia." 


SYMPTOMS — DELUSIONS — DESPONDENCY.  393 

perversions  soon  ensue,  sometimes  evolved  out  of  the  sensorial  dis- 
turbances, often  independent  of  such  states,  but  invariably  intensified 
bv  hallucinatory  and  illusional  phenomena  when  present.  Delusional 
states  were  recognised  in  73  per  cent.,  and  out  of  a  total  of  sixty-one 
deluded  cases,  sixteen  were  victims  to  the  terrible  delusion  that  the 
soul  was  eternally  lost,  and  that  the  subject  was  to  be  consigned  to 
the  flames  of  lieU.  It  is  strange  to  witness  the  prevalence  of  this 
religious  despondency  at  a  period  when,  as  we  are  aware,  the 
generative  organs  are  undergoing  an  important  cyclical  transformation; 
and  to  contrast  it  with  the  converse  states  of  religious  exaltation  sO' 
frequently  associated  with  the  sexual  transformations  and  excitation 
of  adolescence,  of  hysterical  and  epileptic  forms  of  insanity.  Usually 
the  victim  of  this  ailment  accuses  herself  of  the  most  heinous  crimes, 
and  dreads  the  pursuit  of  human  or  spiritual  beings  who  thirst  for  her 
life's  blood ;  but,  at  times,  a  case  presents  a  somewhat  dilferent  char- 
acter of  delusive  belief;  thus,  one  subject  believed  herself  to  be  bitten 
by  venomous  toads,  that  dogs  pursued  her  and  sucked  her  blood  ; 
whilst  another  declai-ed  she  was  fed  on  human  flesh.  Such  delirious 
concepts  are  by  no  means  frequent  in  this  form  of  insanity,  nor  are 
the  patient's  children  or  husband  usually  the  theme  of  her  perverted 
imagination. 

Such  gloomy  forebodings  of  coming  evil  or  the  mental  disquiet 
aroused  by  a  sense  of  her  irrevocable  doom,  eventually  issue  in  suicidal 
promptings,  in  fact,  a  large  proportion  freely  admit  this  tendency. 
We  find  that  of  all  the  cases  of  mental  depression  taken  together 
quite  60  per  cent,  are  actually  suicidal ;  but,  of  the  class  of  patients 
now  under  consideration,  about  44  per  cent,  only  could  be  so  con- 
sidered. Impulses  to  suicide  are  certainly  not  so  frequent ;  yet,  in 
the  worst  cases,  they  do  present  themselves.  Dr.  Clouston  expresses 
the  opinion  that : — "  The  very  loss  of  courage  and  vigour  of  will 
operate  against  any  effectual  attempts  at  suicide " ;  yet  experience 
teaches  that  in  the  worst  forms  most  desperate  attempts  are  occasioii- 
ally  made  with  the  object  of  eluding  the  torture  to  which  the  mind  is 
at  times  subjected  by  the  terror  of  impending  evil.  Thus  one  poor 
victim  of  such  terrors  imagined  herself  haunted  by  evil  spirits,  who 
audibly  told  her  she  was  to  be  burnt  alive,  and,  consequently,  she 
made  a  desperate  attempt  at  hanging  herself;  another  attempted 
strangulation  under  the  impression  of  being  pursued  by  the  evil  one  ; 
a  third  attempts  poisoning  with  vermin-powder,  upon  the  assumption 
that  she  was  "  cast  off  by  God  ";  and  three  others  attempt  to  end  their 
misery  by  drowning,  choking,  or  the  knife,  under  the  influence  of 
similar  perverted  sensorial  states.  Especially  have  we  learnt  to  dread 
the  impulsiveness  of  depression  at  the  climacteric  when  associated  Avith 


394  INSANITY   AT   TUE   CLIMACTEEIC    EPOCH. 

the  tendency  to  drink  lieavily.  Tlie  purely  impulsive  form  of  insanity 
may  appear  at  this  period  of  life ;  and  homicidal,  as  well  as  suicidal, 
impulses  may  characterise  the  case,  apart  from  any  notable  intellectual 
or  emotional  disturbance  whatever.  As  we  have  before  stated,  the 
convulsive  neuroses  are  prone  to  occur  at  all  the  cyclical  epochs  of  life 
with  special  frequency. 

S.  H.,  aged  forty-two,  a  marrieJ  woman,  in  comfortable  circiunstances  at  home, 
was  admitted  suffering  from  severe  mental  depression.  She  was  a  strong,  muscular 
subject  of  medium  height,  but  somewhat  pale  and  anajmic ;  had  a  family  of  three 
children  living ;  and  was  last  confined,  some  eighteen  months  ago,  of  a  still-bom 
child.  Her  habits  of  life  w-ere  affirmed  to  have  been  consistent  and  temperate ; 
and  at  the  present  time  she  was  regarded  as  suffering  from  the  functional  ailments 
incident  to  the  menstrual  climacteric ;  the  menopause  was  not  established  but  much 
irregularity  existed.  Paternal  ancestry  neurotic;  the  father,  who  was  regarded  as 
insane,  had  committed  suicide  on  hearing  of  his  wife's  death.  For  three  months 
she  had  been  melancholic,  and  had  made  repeated  attempts  to  drown,  choke,  and 
suffocate  herself,  and  also  to  cut  her  throat.  Had  expressed  no  delusion,  and  did 
not  sufifer  from  hallucination. 

No  cardiac  or  arterial  disease  was  ai:)parent ;  the  respiratory  and  alimentary 
systems  were  normal.  The  urine  was  1020  specific  gi'avity,  famtly  acid,  and 
devoid  of  albumen  or  sugar.  Catamenia  were  in  arrest.  A  few  days  after  admis- 
sion her  morbid  propensities  declared  themselves,  and  she  attempted,  by  filling 
her  mouth  with  paper,  leaves,  or  anj'thing  at  hand,  to  choke  herself.  Her  restless- 
ness at  night  was  relieved  by  chloral,  and  the  sedative  solution  of  opium  in  20 
minim  doses  was  administered  twice  daily.  Her  aspect  was  expressive  of  a  sour 
discontent,  and  from  being  reserved,  reticent,  and  brooding,  she  developed  hypo- 
chondriacal fancies ;  and  querulously  and  persistently  drew  attention  to  her 
imagined  ailments.  A  slight  attack  of  pleurisy  a  fortnight  after  admission  was 
followed  by  marked  relief  to  her  mental  symptoms,  and  she  left  perfectly  re- 
covered two  months  later.  She  had  not  been  at  home  over  a  fortnight  ere  her 
restless  depression  recurred,  and  further  suicidal  tendencies  led  to  her  readmission 
three  months  subsequently.  Her  condition  was  as  follows : — "Free  from  any  aspect 
of  depression  ;  utterly  indifferent  and  callous  to  her  existing  state ;  admits,  with 
some  flippancy  of  manner,  being  subject  to  sudden  and  incontroUable  impulses  to 
destroy  herself;  no  delusion  or  hallucination  can  be  traced  in  her  account  of 
herself ;  she  is  perfectly  calm,  rational  in  all  her  statements,  and  intelligent. 
Amenorrhcea  has  existed  for  eight  months."  Under  similar  treatment  she  pro- 
gressed during  the  first  mouth  so  far  as  to  be  cheerful,  active,  industrious,  and, 
according  to  her  own  statement,  had  suffered  from  no  return  of  morbid  impulse. 
She  had,  however,  a  somewhat  careless,  flippant  maimer,  which  was  unsatisfactorj' 
as  indicating  a  reduction  in  the  moral  sense  not  natural  to  her.  About  this  time 
she  again  became  somewhat  querulous,  importunate  about  returuing  home,  and 
there  was  slight  hypochondriasis.  This  culminated  in  her  abstracting  from  a 
cupboard  a  quart  bottle  of  spirits,  locking  herself  in  the  bath-room  of  an  olScer's 
house,  and  deliberately  swallowing  the  whole  of  the  contents  of  the  bottle.  She 
was  discovered  in  time  to  rescue  her,  and  on  her  recovery  from  her  semi-comatose 
state  she  avowed  that  she  had  taken  the  spirits  with  suicidal  intent.  Again  she 
became  more  cheery,  less  hyi)ochondriacal,  active,  and  useful,  and  in  six  weeks 
time  she  was  tried  once  more  in  an  associated  dormitory,  where  she  slept  ■with 


IMPULSIVE    STATES.  395 

fifty  otiier  patients.  She  protested  her  freedom  from  impulses  ever  sinec  her  last 
attack,  and  was  most  anxious  to  be  tried  at  home  once  again.  The  night  following 
this  apparently  genuine  statement,  she  retired  to  bed,  and  was  found  in  the  early 
morning  .strangled  by  a  piece  of  braid  which  she  had  secured  and  concealed.  The 
ligature  was  tightly  secured,  the  bed-clothing  perfectly  undisturbed,  and  the 
sheet  drawn  over  the  face  to  secure  her  fi-om  the  observation  of  the  patients  sleep- 
ing beside  her  —  sulEcient  evidence  of  the  desperate  determination  which  had 
initiated  the  act. 

Contrasted  with  the  case  of  S.  II.  we  may  take  that  of  A.  A.^  in  which 
maniacal  perversions  of  a  prominent  nymphomaniacal  nature  prevail. 

A.  A.,  aged  forty-seven,  a  married  woman,  of  steady,  temperate  habits  of  life, 
without  any  ascertainable  neurotic  history  in  her  antecedents,  came  under  treat- 
ment after  two  weeks'  excitement.  She  had  only  recently  been  discharged  from 
another  asylum.  She  was  in  a  state  of  subacute  excitement  iipon  her  admission 
and  was  dangerously  aggressive ;  she  expressed  the  delusion  that  she  was  Queen, 
that  her  liusband  was  king,  and  that  she  held  the  keys  of  heaven  and  hell ;  a  sus- 
picious tendency  was  also  present  which  induced  her  to  refuse  her  food.  She  was 
pale  and  somewhat  haggard  ;  a  hoemic  bruit  was  heard  at  the  base  ;  had  a  furtive 
suspicious  expression,  and  an  agitated  eager  manner ;  spoke  of  a  contest  about  to 
occur  in  the  country  which  she  might  be  able  to  arrest.  She  admitted  being  at  the 
menopause.  For  some  weeks  after  admission  the  excitement  abated  sufficiently 
to  allow  her  to  occupy  herself  usefully.  Soon,  however,  maniacal  symptoms  again 
supervened,  and  she  has  remained  since  this  period  subject  to  outbursts  of  excite- 
ment and  intervals  of  calm.  The  patient  entertained  the  most  bitter  feelings  of 
animosity  against  her  husband  whom  she  repeatedly  accused  of  being  untrue  to 
her ;  she  denounced  him  in  loud  and  threatening  language,  became  most  furious 
and  violent,  and  in  her  frenzy  destroyed  all  within  her  reach.  Upon  one  occasion 
she  tried  to  strangle  herself  by  tying  her  hair  round  her  neck.  "At  these  periods 
of  excitement  she  shows  much  hysterical  emotionalism,  sobs  aloud,  simulates 
physical  ailments,  complains  of  imaginary  pains  or  assumed  grievances,  the  abdo- 
men is  usually  distended  by  flatus,  and  she  then  eructates  for  hours  together. 
She  has  a  peculiarly  wild  agitated  manner ;  is  most  irrational,  deluded,  and 
dangerously  impulsive.  Throughout  her  intervals  of  calm  she  occupies  herself 
usefully ;  but  there  is  always  a  suppressed  under-current  of  excitement  readily 
aroused  by  trivial  circumstances  into  a  passionate  outburst.  She  now  betrays  a 
strongly  erotic  condition  evidenced  by  expression  and  gesture  and  lascivious  re- 
marks ;  when  less  under  self-control  this  tendency  gives  vent  to  repulsive 
and  obscene  language.  She  has  developed  the  delusion  that  one  of  the  asylum 
officials  is  married  to  her,  and  she  repudiates  her  former  husband."  It  is  now 
three  years  since  the  onset  of  her  derangement ;  she  is  incoherent  in  conversa- 
tion, betrays  the  same  agitated  manner,  and  is  subject  to  periodic  attacks  of  wild 
nymphomaniacal  excitement  as  formerly. 

Etiology. — In  endeavouring  to  estimate  statistically  the  influence 
of  tlie  climacteric  involution  upon  the  development  of  forms  of  mental 
alienation  pi-evailing  at  this  epoch,  we  naturally  first  question  oux'selves 
as  to  the  relative  frequency  of  insanity  at  this  and  other  periods  of 
life.     "Were  we  to  take  promiscuously  an  aggregate  of  cases  becoming 


396  INSAXITY    AT    THE    CLIMACTERIC    EPOCH. 

insane  at  different  ages  over  an  extended  series  of  years,  we  should 
become  early  convinced  that  the  question,  far  from  being  a  simi)le 
one,  as  it  might  at  first  be  regarded,  was  really  a  very  complicated 
problem  to  unravel. 

In  the  first  place,  the  population  at  different  ages  of  life  varies ;  so 
that  admissions  in  quinquennial  or  decennial  periods  are  derived  from 
disproportionate  sections  of  the  community.  Hence  we  desire  to 
learn  not  only  the  actual  number  of  cases  of  insanity  occurring  at 
different  ages,  but  also  the  ratio  of  such  numbers  to  the  population  ex- 
isting at  similar  periods  of  life.  Thus  a  glance  at  Table  on  p.  397,  show- 
ing the  relative  frequency  of  insanity  at  different  ages  for  1,808  female 
cases,  admitted  into  West  Riding  Asylum,  indicates  the  period  from 
thirty  to  thirty-five  as  affording  the  highest  number  of  admissions, 
and  that  each  succeeding  quinquennial  affords  a  rapidly  decreasing 
series  of  cases ;  yet,  when  we  come  to  compare  these  numbers  with 
the  existing  population  at  a  corresponding  age,  we  find,  in  lieu  of 
a  rapid  decrease  of  insanity  at  these  years,  that  the  ratio  of  occurring 
cases  is  maintained  at  an  equable  rate  or,  according  to  some  authorities, 
is  even  increased. 

In  the  next  place,  our  statistics  would  embrace  subjects  from  most 
varied  conditions  of  life  and  occupation,  each  sphere  of  life  bringing  its 
own  disturbing  and  exciting  elements  into  the  field ;  hence  it  is  advis- 
able, in  estimating  the  influence  to  be  attached  to  the  climacteric,  to 
compare  only  that  class  of  the  community  whose  social  status  exposes 
them  to  more  or  less  similar  conditions  of  life.  Unless  this  be  done, 
we  may  drift  into  the  error  of  attributing  to  a  physiological  cycle 
solely,  what  might  more  reasonably  be  expounded  upon  other  grounds 
— the  encroachment  of  environmental  agencies.  The  Avealthy  and  the 
pauper  class  (exposed  as  they  are  to  such  widely-different  exciting 
agencies)  must  be  judged  apart  upon  the  respective  merits  of  their 
cases,  for  any  such  statistics  embracing  all  sections  of  the  communit}', 
irrespective  of  class  distinctions,  must  be  more  or  less  vitiated  thereby. 
In  the  next  place,  we  must  not  forget  that  we  are  dealing  with  other 
important  social  factors — the  single,  the  mai'ried,  or  the  widowed  state; 
and,  that  our  aggregate  certainly  includes  a  number  of  relapsed  and 
recurrent  cases,  in  which  a  well-marked  predisposition  to  insanity 
existed,  and  in  which,  therefore,  the  climacteric  epoch  simply  supplies 
the  disturbing  forces. 

In  our  attempts  to  classify  such  forms  as  appeared  more  especially 
dependent  upon  the  climacteric  change,  we  found  it  essential  to 
eliminate  a  very  large  proportion  of  cases  occurring  at  this  period  of 
life.  Recurrent  cases  had  obviously  to  be  rejected,  and  so  had  all 
forms  of  insanity  Avhich  had  not  originated  at  this  epoch  of  life ;  and 


INCIDENCE    OF    INSANITY    IN    4,085    CASES. 


397 


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398  IXSAKITY    AT   THE    CLIMACTERIC    EPOCH. 

SO  also  cases  of  epilepsy,  imbecility,  and  organic  brain  affections,  where 
the  climacteric  was  .but  the  spark  to  the  fulminate.  This  rigid 
exclusion  of  dubious  cases  left  but  a  meagre  residue  of  eighty  out  of 
1,808  cases,  or  a  percentage  of  44  upon  the  total  admissions.  The 
astonishing  disparity  in  estimates  upon  this  point  by  different  writers 
is  seen  in  the  following  table  : — 

Classed  as  Climacteric  Insanity. 

■n^-A-^  Ti„.,^«ii                                  Skae'a  Edin-  Clouston's  Edin-  ,.,„„„„.„  Trr^of  Bevan  Lewis' 

EeidsHanw5ll                                  burgh  Eoyal  bur?h  Royal  Merson  s  West  WestBidiDg 

Statistics  of  ,03  Tilt  s  Statistics.        A.vluni.  Asylum,  Kidmg  Asylum,  Asvlum, 

Cases  of  Insamty.                                  5o8  Cases.  1,549  Cases.  I,0o4  Cases.  i^gOS  Cases. 

1-1%  3  to  4%  11-1  7o  12-6%  14  to  15%         4-4% 

Obviously  from  the  above  the  discrepancy  must  be  involved  in  the 
personal  equation ;  in  fact,  in  the  want  of  unanimity  of  opinion  as  to 
what  really  constitutes  the  criterion  of  a  so-called  case  of  climacteric 
insanity.  It  will  be  observed  that  our  estimate  (founded  upon  personal 
observation)  closely  agrees  with  that  of  Dr.  Tilt,  and  we  differ,  there- 
fore, in  regarding  his  results  as  an  under-estimate ;  *  at  the  same  time 
we  glean  from  Dr.  Merson's  able  paper  f  the  real  cause  of  such  dis- 
crepancy.    He  there  states  in  reference  to  his  percentage  of  15  that: — 

"It  by  no  means  follows  that  in  all  these  cases  the  climacteric  condition  was 
the  only,  or  even  tlie  chief,  element  in  the  causation  of  the  mental  disorder,  though 
it  may  be  affirmed  that  in  most  cases  it  exercised  a  causative  or  modifying  influence 
more  or  less  marked.  The  history  of  the  cases  investigated  points  to  the  conclusion 
that  the  change  of  life  is  not  often  of  itself  the  immediate  cause  of  insanity.'' 

The  same  writer  then  proceeds  to  particularise  76  out  of  his  149  cases 
as  influenced  by  other  exciting  agencies,  giving  amongst  such  some  31 
cases  of  organic  brain  disease,  cases  of  alcoholic  excess,  &c.  Clearly 
such  cases  would  not  comprise  pure  cases  of  so-called  climacteric  insanity 
as  understood  by  Dr.  Skae,  and  with  this  qualification  we  fully  agree 
with  Dr.  jMerson's  remarks  on  causation  quoted  above.  Our  own 
tables,  which  give  but  4*4  per  cent.,  include  only  such  cases  where  the 
disturbances  of  the  climacteric  change  and  menopause  were  uncom- 
plicated with  other  potent  exciting  agencies,  and  where  we  could 
justifiably  presume  that  the  insanity  was  the  more  immediate  outcome 
of  this  revolutionary  period. 

In  what  way  is  this  physical  predisposition  to  insanity  incurred? 
From  the  standpoint  of  the  evolutionist,  we  are  led  to  observe  that  the 
crrowth  and  development  of  the  nervous-system  is  but  a  progressive 
representation  and  re-representation  in  ever-advancing  and  more  com- 

*  PsychoIo[/'ical  Medicine,  Drs.  Bucknill  and  Tuke,  3rd  edit.,  p.  360. 

+  "  Climacteric  Period  in  Relation  to  Insamty,"  W.  B.  A.  ]ie2)oris,  vol.  vi.,  1S76. 


ETIOLOGICAL    FACTORS.  390 

plex  terms  of  the  wliole  organism ;  tliat  the  cci-cbrum  itself  is  but  a 
vast  assemblage  of  sncli  liighly-complex  representative  realms ;  and 
that  in  the  higher  realms  such  nervous  mechanisms  as  foi'm  the 
jihysical  expression  of  such  representation  have  linked  to  them  the 
psychical  correlatives  of  feeling  and  of  thought.  The  loss  of  any  portion 
of  the  organism  which  has  entered  largely  into  our  conscious  life,  or,  in 
other  words,  has  been  frequently,  or  at  all  largely,  represented  in 
consciousness,  will  necessarily  disturb  the  mental  balance.  Nor  could 
it  be  reasonably  conceived  that  a  portion  of  the  body  which  had  long 
subserved  the  wants  of  the  organism,  and  whose  physiological  history 
was  represented  in  certain  organised  tracts  of  the  cerebrum,  could 
suffer  ablation  without  some  attendant  commotion  in  the  brain.  In 
.fact,  the  systemic  and  least  relational  structures  are  in  their  genesis  so 
closely  interwoven  with  the  physical  substrata  of  feeling  and  emotion 
that  wide-spread  disturbance  results  from  their  derangements,  functional 
and  organic.  The  enormous  share  taken  by  the  generative  system  in 
the  physiological  and  psychological  life  of  the  female  is  a  subject  of 
2)araraount  importance  in  our  studies  of  the  varieties  of  insanity.  The 
organs  subservient  for  some  five-and-thirty  years  or  longer  to  the 
important  functions  of  menstruation,  ovulation,  gestation,  lactation, 
lind  their  nervous  rejoresentatives  in  the  fundamental  tracts  of  the 
nervous  system,  and  draw  largely  upon  that  system  during  their  life  of 
functional  activity.  Periodic  relays  of  nerve-force  demanded  for  the 
regulation  of  their  blood-supply  and  of  their  muscular  apparatus,  and 
the  ingoing  currents  crowding  upwards  from  so  extensive  a  system, 
enter  intimately  into  the  very  web  which  forms  the  physical  correla- 
tives of  emotions  and  moral  instincts.  The  vast  accession  of  new  impres- 
sions registered  by  the  sensoriuni  when  these  organs  awake  to  functional 
activity  during  puberty  has  a  most  profound  effect  on  the  mental 
constitution — an  effect  whose  significance  cannot  be  misinterpreted; 
for  the  result  is  a  real  transfOPmation,  more  or  less,  of  the  eg'O, 
with  all  its  feelings,  emotions,  sentiments,  and  desires.  At  each 
subsequent  periodic  crisis  incident  to  menstruation,  gestation,  lactation, 
uterine  involution,  the  nervous-centres  are  profoundly  affected  by  the 
resultant  transformations  undergone,  such  periods  being  eminently 
periods  of  nerve-instahility. 

Pre-eminently  is  this  the  case  at  the  menopause  and  grand  climac- 
teric, when  the  whole  of  this  system  loses  its  functional  activity, 
degenerates,  and,  in  fact,  passes  almost  completely  out  of  the  life  of 
the  individual.  Both  subjective  and  objective  accompaniments  of  the 
menstrual  molimen  in  a  greatly-exaggerated  degree  emphasise  and 
usher-in  this  serious  distui-bance  of  the  nervous-centres — headache, 
vertigo,  faintness,  "heat-flushes,"  emotional  waves,   phases  of  moral 


400  INSANITY    AT    THE    CLIMACTERIC    EPOCH. 

perversity,  irritability,  querulous  impatience,  even  intellectual  disturb- 
ance (especially  of  memory  and  of  attention)  prevail ;  and,  wanting  the 
relief  aftbrded  by  the  depurative  ])rocess  of  menstruation,  the  distress 
is  often  a  long-continued  and  urgent  one.  This,  however,  is  the  earlier 
stage  of  functional  decrepitude,  the  early  phase  of  which  is  characterised 
by  want  of  decision,  lassitude,  and  hebetude.  It  is  essentially  a  period 
of  voluminous  emotions,  purposcdess  waves  of  feeling,  abortive  yearn- 
ings, redundant,  vague,  uncontrolled  desires,  and  misdirected  energy. 
That  great  reservoir  of  nerve-force,  which  had  for  its  object  the  jiro- 
creative  functions  of  the  organism,  is  now  objectless,  and  its  expendi- 
ture must  now  be  directed  into  other  channels ;  a  period  of  emotional 
instability  ushers-iu  a  period  of  reconstructions. 

J.  F.,  aged  forty-one,  single;  admitted  January,  18S0.  Patient's  father  was  very 
intemperate;  her  mother  and  brother  liad  been  inmates  of  this  asjdum.  J.  F.'s  life 
had  been  a  very  unhappy  one.  For  many  years  she  had  been  compelled  to  dwell 
with  her  brother,  a  brutal,  drunken  scoundrel.  During  the  two  months  before 
being  taken  to  the  asylum,  she  had  developed  dangerous,  impulsive  tendencies, 
suddenly  striking,  biting  at,  and  kicking  those  happening  to  be  around  her. 
"When  admitted,  a  condition  of  fairly  calm  attention  and  apprehensiveness  was 
constantly  interrupted  b}^  outbursts  of  furious  excitement  and  violence.  An  insane 
self-con :,'ratulation  in  her  power  of  occasioning  terror  by  her  actions,  seemed 
possibly  of  influence  iu  the  production  of  her  paroxj'sms  of  passion. 

For  three  months  she  was  liable  to  these  dangerous  impulses,  of  which  she  was 
aware,  and  expressed  her  grief  at  being  unable  to  restrain  them.  Subsequently  she 
passed  through  phases  of  suUenness,  depression,  and  agitation,  to  quietude  and 
industry.  The  catamenia,  absent  on  her  admission,  returned  during  her  latter 
period  of  convalescence. 

This  epoch  of  reconstructions  is  one  of  peril  to  the  mind,  especially 
to  those  ill-trained  mental  constitutions  in  which  the  passions  have 
been  allowed  an  uncontrolled  expression  ;  and  where  intelligent  guid- 
ance has  been  denied  to  the  instinctive  desires.  In  fresh  objects  of 
affection,  in  new  pursuits,  aims,  and  studies,  in  other  forms  of  mental 
culture  many  minds  will  seek  and  obtain  relief  for  these  perturbed 
feelings  and  pent-up  emotions.  The  anxious  and  intelligent  mother 
will  find  a  sufficient  object  in  the  prospective  life  and  well-being  of  the 
offspring ;  many  cultured  minds  will  find  in  the  fields  of  literature  a 
sufficient  relief  to  their  pent-up  energies ;  whilst  those  who  lack  in 
such  facilities  will  perhaps  bend  their  attention  towards  schemes  of 
education  or  charitable  movements ;  and  the  instances  are  not  few 
where  the  political  s})irit  of  the  times  affords,  in  our  day,  missions  for 
the  .same  subjects.  The  peril  of  this  perh)d  is  one  incident  to  all 
periods  of  reconstruction  arising  during  emotional  turmoil  and  pertur- 
bation, lietlection  -wants  the  calm  essential  to  its  orderly  operation, 
and  judgment  is  liable  to  be  warped  and  one-sided;  hence,  also,  it  is 


ETIOLOGY — PROGNOSIS.  401 

that  this  age  of  life  is  one  prone  to  bigotry,  to  religious  fanaticism,  or 
to  conduct  based  upon  dogmatic  and  immature  beliefs.  An  unusual 
and  inordinate  religious  zeal  is,  indeed,  a  most  frequent  expression  of 
this  transition-period  in  mental  life ;  and  tliis  is  of  interest  viewed  in 
connection  with  the  characteristic  delusions  of  the  insanity  of  this  age. 

"NVe  hear  of  a  similar  climacteric  in  man ;  but  the  parallel  is  more 
fanciful  than  strictly  correct.  Even  its  advocates  who  speak  of 
climacteric  insanity  in  man,  allude  to  it  as  occurring  "  at  a  later  time 
of  life  than  in  the  female,  .  .  .  much  more  irregular  and  indefinite. 
There  is  nothing  to  mark  it  off  so  clearly  as  the  menopause"  (Clouston).* 
The  period  assigned  for  the  decline  of  the  procreative  power  in  man 
is  55  to  G5 ;  in  fact,  the  borderland  of  senility  and  not  a  genuine 
epochal  transformation.  As  Barnes  states : — "  There  is  nothing  to 
compare  with  the  almost  sudden  decay  of  the  organs  of  rejDroduction 
which  marks  the  middle  age  of  woman." f  With  a  certain  proportion 
of  cases  the  menopause  in  woman  may,  in  like  manner,  usher-in  pre- 
mature senility;  but,  in  all,  its  more  or  less  sudden  onset  and  the  great 
constitutional  changes  and  local  transformations  wrought,  frequently 
followed  by  the  subject  taking  up  an  entirely  new  lease  of  life,  give  to 
this  period  a  critical  character  wholly  distinct  from  what  we  see  in  man. 

Prog'nosis. — The  ultimate  issue  of  an  ordinary  uncomplicated  case 
of  insanity  at  the  climacteric  may  certainly  be  considered  a  favour- 
able one ;  favourable,  that  is,  as  regards  the  duration  of  the  malady, 
favourable  as  regards  the  stability  of  the  reinstatement,  and  favourable 
as  contrasted  with  the  recoverability  of  all  cases  of  insanity  in  the 
female  when  taken  collectively.  Even  when  all  cases  of  insanity  at 
this  period  of  life  are  considered,  whether  of  recent  or  of  remote  origin, 
complicated  or  otherwise,  still  one-half  of  such  cases  constitute  absolute 
recoveries ;  and  the  favourable  progress  of  the  affection  is  indicated  by 
the  fact  that  three-fourths  of  the  recoveries  take  place  within  nine 
months  of  the  onset  of  the  attack. 

What,  then,  are  the  special  features  which  serve  to  demarcate  the 
favourable  from  the  unfavourable  class  1  what  are  the  elements  which 
enter  into  a  favourable  prognosis  and  the  reverse  1  The  hopes  we  can 
give  to  our  patient's  friends  of  a  perfect  recovery  will  largely  depend 
upon  the  "  ti^ne  element,"  which  plays  so  impoi'tant  a  role  in  determining 
the  prognosis  in  most  forms  of  insanity.  An  early  and  rapid  cure  is, 
as  in  other  cases,  favoured  by  early  treatment ;  and  the  chances  of  a 
complete  and  speedy  recovery  are  much  strengthened  if  the  subject 
come  under  appropriate  treatment  within  two  weeks  of  the  onset  of  her 
symptoms.     We  would  emphasise  here  the  sjjeedi/  return  to  a  normal 

*  Op.  cit.,  p.  560. 

t  Clinical  History  of  the  Diseases  of  Women,  Burues,  p.  263. 

26 


402  INSANITY    AT   THE    CLIMACTERIC    EPOCH. 

mental  vigour,  for  it  is  in  this  particular  that  early  treatment  is  so 
desirable.  The  actual  numerical  result  of  recoveries  coming  under 
treatment,  from  a  week  up  to  three  months  after  the  onset  of  their 
symptoms,  is  about  the  same  for  all  (50  to  GO  per  cent,  being  recoveries); 
but,  beyond  three  months,  fewer  actual  recoveries  occur,  and  a  large 
aggregate  will  be  relegated  to  the  class  of  the  chronic  insane. 

Will  the  recovery  be  a  stable  one,  or  will  the  attack  subject  the 
patient  to  further  liability  1  As  a  general  rule  it  may  be  affirmed  that 
the  more  fully  the  affection  realises  the  character  which  is  regarded  as 
typical  of  a  truly  epochal  form  of  insanity,  i.e.,  the  more  fully  it 
appears  to  be  the  issue  of  disturbances  incident  to  this  period  of  life, 
the  more  likely  is  the  return  to  normal  health  to  prove  a  secure  and 
permanent  state.  Hereditary  predisposition  will,  of  course,  in  such 
cases  produce  its  usual  results,  subjecting  the  victim  at  any  period  to 
a  relapse  on  the  incidence  of  exciting  agencies ;  and  the  predisposing 
influence  of  former  seizures  will  also  have  to  be  considered  and  allowed 
for  in  framing  our  reply  to  this  query.  An  actual  study  of  our  cases  of 
insanity  at  the  climacteric  shows  that  some  27*7  per  cent,  had  a  family 
predisposition  to  insanity  ;  and  that  38  per  cent,  of  the  total  cases  had 
suffered  from  a  previous  attack  of  mental  derangement.  Yet  the 
actual  relapse  after  confirmed  recovery  from  this  form  of  insanity 
occurred  but  in  four  instances  out  of  the  whole  sei'ies  of  eighty-three, 
and  in  three  of  these  a  predisposition  to  insanity  was  indicated  by  a 
former  attack  in  earlier  life  with  strong  hereditary  taint. 

Another  point  of  importance  in  prognosis  to  recall  is  the  mortality 
incident  to  this  affection.  The  deaths,  which  amount  to  14-4  per  cent, 
at  the  West  Riding  Asylum,  are  due  to  intercurrent  affections,  in 
which  phthisis  or  pneumonia  play  the  chief  part ;  in  fact,  one-half  the 
deaths  occurred  amongst  the  chronic  class  who  had  resided  at  the 
asylum  for  a  period  of  from  two  to  six  years.  It  may  be  stated,  indeed, 
that  the  insanity  incident  to  this  period  is  rarely,  if  ever,  fatal  in 
itself;  and  the  chronic  remnant  of  this  class  owe  their  unfavourable 
character  chiefly  to  the  exhausting  influence  of  chronic  pulmonary 
disease,  ulcerative  affections  of  the  bow^els,  or  the  malnutrition  and 
defective  blood-supply  of  the  brain,  due  to  an  enfeebled  and  fatty  heart. 
Another  factor  in  the  jn'ognosis  is  the  age  of  the  patient.  It  has  been 
observed  by  Dr.  Clouston  that  fewer  recoveries  occur  after  fifty  years 
of  age — an  opinion  with  wliich  we  concur.* 

The  previous  habits  of  the  patient  must  likewise  be  taken  into 
account,  and  especially  does  this  apply  to  the  use  of  alcoholic  stimu- 
lants, so  frequently  indulged  in  at  this  period  of  the  woman's  life.  It 
is  a  well-known  fact   that  seci-et  drinking-habits  become   peculiarly 

*  Loc.  cH.,  p.  564. 


PROGNOSTIC    INDICATIONS.  403 

frequent  at  this  era,  a  morbid  craving  for  stimulation  being  engendered 
by  the  depression  entailed  at  this  period  of  reconstruction.  If  this 
vice  has  been  contracted  the  malady  always  appears  in  an  aggravated 
form.  The  very  nature  of  the  mental  disturbance,  the  delusional 
melancholia  often  bordering  upon  a  hypochondriasis,  and  always  of  a 
self  accusatory  character,  finds  in  this  grievance  a  sure  foundation  for 
its  gloomy  fears  and  genuine  despair;  these  cases,  as  already  indicated, 
are  peculiarly  prone  to  suicidal  impulse.  Such  subjects  may  exhibit 
much  outward  calm,  have  an  absent  manner,  a  self-engrossed  aspect, 
or  a  suspicious  furtive  reticence,  or  betray  on  their  features  the  set 
asj>ect  of  despair — indications  which  should  place  us  on  our  guard. 

The  question  of  time  during  which  the  alienation  has  existed,  the 
age  of  the  patient,  her  hereditary  predisposition  to  insanity, 
and  the  acquired  predisposition  through  alCOholic  indulg'ence  are 
some  of  the  chief  factors  which  enable  tis  to  arrive  at  our  prognosis  in 
the  case. 

Very  divergent  views  have  been  expressed  with  respect  to  the 
prognosis  in  climacteric  insanity.     Thus  one  authority  says  : — • 

"Climacteric  insanity  is  far  from  being  a  hopeful  form  of  mental  derangement."* 
Van  der  Kolk  states — "If  religious  melancholy  begins  in  the  clmiacteric  years, 
then  the  prognosis  is  unfavourable;"  whilst  Dr.  Merson  says — "The  history  of 
the  cases  I  have  investigated,  however,  shows  that  as  regards  ultimate  recovery 
the  prognosis  is  by  no  means  unfavourable,  though  an  early  recovery  is  not 
generally  to  be  expected,  "t 

Dr.  Clouston  gives  a  percentage  of  57  for  recoveries  in  the  female 
sex;  I  Dr.  Merson's  table  realising  59*5  per  cent.,  or  47  per  cent,  when 
cases  uncomplicated  with  epilepsy,  general  paralysis,  and  other  brain 
diseases  were  excluded.  Our  later  statistics,  it  will  be  seen,  afford  us  a 
x-ecovery-rate  of  48  per  cent.,  and,  therefore,  justify  the  views 
expressed  by  Dr.  Merson. 

What  is  the  issue  of  the  attack  in  the  more  unfavourable  cases  1 
It  appears  that  about  36  per  cent,  form  an  incurable  chronic  residue, 
and  about  14  per  cent,  meet  with  a  fatal  termination,  half  of  which 
fatal  cases  also  are  derived  from  the  chronic  class.  Yet  these  un- 
fiivourable  cases  do  not  necessarily  demand  asylum-supervision ;  in 
fact,  one-half  at  least  become  relegated  to  the  home-circle  again,  and 
are  able  to  discharge  in  a  fair-ly-satisfactory  manner  the  duties  of  the 
wife  or  mother,  or  compete  for  livelihood  in  their  various  spheres. 
Such  incomplete  recoveries  are  instances  of  a  permanent  mental  en- 
feeblement,  but  are  by  no  means  subject  to  the  recurrence  of  acute 

*  Psijchological  Medicine  (Drs.  Bucknill  and  Tuke),  p.  145. 
t  W(sst  Riding  Asylum  Reports,  vol.  vi.,  p.  107. 
t  hoc.  cit.,  p.  56.3. 


404  IN'SANITY    AT   THE    CLIMACTEEIC    EPOCH. 

symptoms.  They  remain  mental  wrecks  after  the  storm,  the  depth  of 
reduction  varying  much  for  each  individual  case.  Quiet,  orderly,  in- 
offensive, they  need  only  the  kiadly  guidance  of  the  home-circle  to 
keep  them  right;  yet,  they  exhibit  an  unwonted  apathy,  an  indifference 
to  former  pursuits  and  pleasures,  a  lack  of  energy — mental  and  physical 
— which  was  present  in  their  old  selves.  At  times  depressed,  they  never 
show  active  suicidal  symptoms ;  but  exhibit  a  flabbiness  of  purpose 
and  will,  which  render  them  for  lifetime  the  dependents  upon  a  stronger 
mind. 

There  is  a  remnant  left,  however,  of  these  climacteric  cases  where 
the  issue  is  far  different,  and  where  some  of  the  worst  forms  of  incur- 
able delusional  insanity  become  established.  Here  aural  hallucinations 
largely  prevail,  and  a  sexual  element  often  appears  to  enter  into  the 
material  of  their  delusions.  Hours  are  spent  at  the  windows  listening 
to  the  communications  of  these  unseen  agencies ;  to  w^hich  passionate, 
•wild  outbursts  of  obscenity  and  abuse  often  succeed  from  the  infuriated 
victim.  Such  attacks  of  excitement  largely  prevail  at  night;  and  the 
delusions  based  upon  such  sensorial  anomalies  lead  to  aggressive  and 
destructive  conduct.  For  many  years  these  subjects  remain  a  prey  to 
their  deluded  fancies ;  are  usually  self-opinionated,  or  arrogant,  over- 
bearing, defiant  in  demeanour,  and  form  a  section  of  the  more  noisy 
and  dangerous  class  in  our  asylum-wards.  In  such  cases  we  can  only 
hope  for  the  speedy  advent  of  a  dementia  before  which  the  painful 
sensorial  states  and  delusional  perversions  fade,  while  a  settled  calm 
and  negative  state  of  mind  take  the  place  of  former  turmoil. 

Treatment. — A  tonic  regimen  is  desirable  in  most  cases  of  insanity 
at  this  epoch  of  life.  Open-air  exercise  should  be  enjoined ;  a  free 
nutritious  diet  devoid  of  stimulants  :  and  careful  attention  to  the 
2)rimce  vio>.  An  aloetic  purgative  is  often  desirable  at  the  onset, 
followed  by  mild  laxatives,  of  which  the  mineral  waters  are  a  con- 
venient form  of  administration.  Our  experience  teaches  us  that  a 
large  proportion  of  cases  recover  without  any  form  of  medicinal  treat- 
ment ;  the  removal  from  their  homes,  the  influence  of  new  associations, 
and,  above  all,  the  strict  attention  to  dietetic  treatment  sufiicing  to 
ensure  a  cure. 

There  are  certain  cases,  however,  whei'e  medicinal  interference  is 
imperatively  demanded.  Ansemia  must  be  met  by  the  administration 
of  iron,  pi'eferably  in  the  form  of  the  ammonio-citrate,  and  in  combi- 
nation with  small  doses  of  the  liquor  arsenicalis.  Iron  should  not  be 
given  if  acute  symptoms  prevail  either  of  the  maniacal  or  melancholic 
stamp.  We  should  await  the  subsidence  of  these  symptoms,  meanwhile 
trusting  to  agencies  for  ensuring  sleep  and  to  a  liberal  diet. 

If  there  be  a  tendency  to  refuse  food,  we  must  not  permit  our  patient 


TREATMENT    OF    CLIMACTERIC    IXSAXITY.  -105 

to  escape  on  tlie  excuse  of  having  partially  taken  her  meal  ;  a  due 
amount  of  milk  and  eggs  with  beef-tea,  nourishing  soups,  and  farinaceoua* 
food  should  be  rigidly  insisted  upon  ;  and,  if  necessary  to  resort  to 
fcjrce,  compulsoi'y  feeding  must  be  adopted. 

Sleep  must  be  secured  by  the  adminstration  of  chloral,  bromide  of 
potassium  or  paraldehyd  ;  of  which  we  certainly  give  preference  to  the 
Urst.  It  is  rarely  necessary  to  give  larger  doses  than  25  or  30  gi^ains  ; 
and  where  from  cardiac  enfeeblement  its  use  is  inadmissible,  paraldehyd 
may  be  substituted  with  good  results. 

The  indiscriminate  use  of  sedatives  in  these  cases  is,  we  think,  to 
be  deprecated ;  and,  only  in  the  more  acutely-stamped  types  would  we 
feel  justified  in  the  more  continued  w&e  of  sedatives.  For  this  purpose 
chloral  in  combination  with  bromide  of  potassium  is  the  safer  ti'eatment 
to  adopt;  opium  or  morphia,  henbane  and  conium  have  proved  un- 
satisfactory in  our  hands.  The  bromide  given  separately  from  the 
chloral  we  have  less  confidence  in,  and  the  combination  found  most 
desirable  is  15  grains  of  chloral  with  30  grains  of  bromide  twice  daily. 
We  by  no  means  share  in  the  unfavourable  view  expressed  by  some  as 
to  the  general  inutility,  or  even  hurtfulness,  of  sedative  treatment  in 
the  acute  forms  of  mental  ailment  at  this  epoch ;  given  the  means  of 
securing  efiicient  alimentation,  such  treatment  is  often  followed  by 
the  best  results. 

SENILE    INSANITY. 

Contents.— Mental  Derangements  Incident  to  Senility — Senile  Mania — Senile  Melan- 
cliolia — Chronic  Cerebral  Atrophy — Senile  Convulsions — Senile  E^iilepsy — Senile 
Dementia — Inheritance  as  a  Factor  in  Senile  Insanities — Exhaustive  Brain-work 
— Alcohol  and  Senility — Case  of  T.  G. — Onset  and  Prodromata — Character  of 
the  Senile  Reductions — Senile  Hypochondriasis  (J.  A.) — Senile  Atrophy  and 
Thrombosis  (I.  B.) — Acute  Senile  Melancholia  and  Syncopal  Attacks  (H.  D.)— 
Partial  Exaltation  in  Senile  Insanity— Delusional  Perversions  of  the  Mono- 
maniac and  Senile  Subject  Contrasted  —  Senile  Amnesia  — Cases  of  Senile 
Insanity  (M.  H.  and  M.  I\I.) — Elimination  of  Urea  in  Chronic  Cerebral  Atrophy 
and  Premature  Senility — A  Local  Manifestation  of  Chronic  Bright's  Disease. 

The  student  is  apt  to  mis-apply  the  term  senile  insanity,  that  form  of 
senile  decrepitude  which  is  but  a  morbid  exaggeration  of  j^^il/siological 
senility ;  that  gradual  obnubilation  of  mind  known  as  senile  dementia  is 
apt  to  be  taken  as  a  tyjie  of  what  is  implied  by  senile  insanity;  and,  so 
far  is  he  right,  that  it  is  doubtless  true  that  a  far  larger  proportion  of 
cases  of  mental  impairment  in  senility  belong  to  this  than  to  any  other 
category  of  mental  ailment.  He  is,  however,  too  apt  to  assume  that 
all  varieties  of  mental  ailments  in  the  aged  issue  in  senile  dementia ; 
and  that  the  maniacal  excitement  which  is  so  frequently  observed  at 
this  time  of  life  is  necessarily  the  accompaniment  or  the  precui'sor  of 


406  THE    INSAXITY    OF   THE    SENILE    EPOCH. 

senile  decay.  It  is,  therefore,  necessary  to  inrlicatc  that  this  term 
connotes  a  very  large  class  of  symptoms,  emijracin;,'  between  them  all 
the  varied  forms  of  insanity  usually  differentiated.  The  pathology  of  old 
age  is  as  unique  and  interesting  as  that  of  infancy  and  adult  life;  and, 
just  as  we  are  aware,  that  certain  periods  of  life  bestow  a  special 
immunity  from  certain  morbid  aflections,  so  do  we  find  old  age  by  no 
means  an  exception  to  this  rule.  That  it  has  its  own  special  affections 
of  the  central  nervous-system,  as  of  the  body  at  large,  is  also  a  well- 
established  fact;  and  that  such  morbid  changes  are  characterised  by  a 
special  tendency  towards  atrophy  has  long  been  recognised. 

Apart,  however,  from  such  special  immunities  and  proclivities  as 
this  period  of  life  is  apt  to  entail,  there  are  other  forms  of  mental 
alienation  common  to  it  and  to  adult  life  which  must  be  taken  account 
of  ere  a  faithful  picture  of  senile  insanity  can  be  framed.  Simple 
melancholic  states,  maniacal  perversions,  in  themselves  recoverable 
forms;  or  more  obstinate  delusional  perversions  with,  or  without, 
permanent  dementia,  paralytic  dementia,  the  dementia  of  chronic 
cerebral  atrophy,  epilepsy,  and  even  general  paralysis,  may  severally 
be  encountered  during  advanced  senility  in  the  predisposed.  Yet,  it 
is  none  the  less  true  that  such  affections,  more  common  at  other  epochs 
of  life,  are  considerably  modified  by  the  physiological  stadium,  and  are 
stamped  with  a  special  impress  which  more  or  less  distinguishes  each 
form  of  senile  alienation  from  the  psychosis  of  earlier  periods  of  life. 

A  careful  study  of  insanity  amongst  the  senile  admissions  into  our 
asylums,  and  an  attem2)t  at  a  rational  classification  into  groups  accord- 
ing to  their  most  obvious  pathological  indications,  will  cause  the 
student  much  perplexity  at  first,  owing  to  the  extreme  multiplicity  of 
symptoms  which  he  encounters  amongst  such  cases.  He  will  early 
learn,  through  the  painful  experience  of  a  faulty  diagnosis,  that  it  is 
easy  to  confound  functional  derangements  with  the  earlier  indications 
of  organic  brain-disease;  and  he  must  be  fully  prepared  to  find  his 
prognosis  stultified,  unless  due  attention  be  paid  to  the  modifying 
influences  of  the  senile  epoch  over  the  nature  and  course  of  the  disease. 

Senile  Mania. — He  will  meet  with  forms  of  simple  maniacal  excite- 
ment without  any  very  obvious  enfeeblement  of  the  intellectual 
faculties,  in  which  emotional  instability,  incessant  garrulity,  and  rest- 
lessness are  the  only  obvious  disturbances  recognised.  Such  excitement 
may  vary  from  one  of  slight  degree  to  very  acute  forms;  and,  in  the 
latter  case,  may  prove  most  persistent  and  most  obstinate  to  all 
remedial  agencies.  The  rambling  disconnected  speech  may  pass  into 
utter  incoherence,  the  motor  restlessness  become  extreme,  and 
insomnia  defy  all  our  means  of  relief.  Such  cases  of  senile  mania  may 
require  long-continued  and  forcible  feeding,  and  cause  us  much  anxiety 


MENTAL    DERANGEMENTS    INCIDENT   TO    SENILITY.  407 

lest  a  fatal  degree  of  exhaustion  ensue.  And  yet,  such  cases,  although 
often  the  precursors  of  permanent  dementia,  may  completely  recover 
and  leave  our  patients  with  scarcely  a  vestige  of  mental  enfeeblement 
apparent,  beyond  what  is  natural  to  their  time  of  life.  It  is  to  the 
distinction  between  such  recoverable  forms,  and  those  intercurrent 
attacks  of  mania  which  are  frequent  during  progressive  senile  atrophy 
of  the  brain,  that  the  student  Avill  have  his  attention  chiefly  directed. 
Recurrent  maniacal  attacks  are  of  special  frequency  amongst  the  aged 
iiisauo,  who  are  prone  to  explosive  discharges  from  their  ill-nourished 
and  highly-unstable  cerebrum ;  and  such  recurrent  seizures  are  notably 
present  in  those  senile  cases  who  have  acquired  a  predisposition  through 
alcoholic  indulgence. 

Senile  Melancholia. — A  second  group  of  cases  is  presented  in  those 
forms  of  simple  melancholic  depression  to  which  certain  predisposed 
subjects  are  liable  during  the  physiological  involution  of  the  nerve- 
centres  on  the  advent  of  senility.  Depression  at  this  epoch  is  always 
of  most  ominous  import;  it  may  be  the  precursor  of  senile  mania,  it  may 
usher-in  hopeless  forms  of  senile  dementia,  or  it  may  be  the  warning- 
note  of  those  serious  forms  of  dementia  which  are  connected  with  an 
interstitial  or  gross  cerebral  change,  such  as  occur  in  chronic  cerebral 
atrophy  with  its  scleroses,  or  hsemorrhages,  or  softening  from  thrombi. 
Here,  again,  the  student  will  find  his  attention  profitably  directed 
towards  the  diagnostic  distinctions  betwixt  simple  senile  melancholia 
as  a  purely  functional  ailment  (which  is  a  fairly  recoverable  form  of 
alienation),  and  the  depression  which  augurs  a  serious  structural 
change  in  the  nervous-centres.  As  we  shall  see  later  on,  such  forms  of 
simple  melancholia,  unaccompanied  by  any  delusional  state,  are  notably 
characterised  by  their  strongly-marked  suicidal  tendency,  which  appears 
in  79  per  cent,  of  such  cases. 

Chronic  Cerebral  Atrophy. — Passing  by  these  simple  forms  of 
aflfective  insanity,  we  arrive  at  a  third,  and  a  very  interesting,  group  of 
cases,  which,  whether  the  symptoms  be  considered  from  the  mental  or 
physical  side,  present  evidence  of  a  very  definite  pathological  process — 
we  allude  to  chronic  cerebral  atrophy.  This  is  an  afiection  no  more 
limited  to  senility  than  the  foregoing,  yet  it  is  of  special  occurrence  at 
advanced  age.  The  affective  sphere  of  mind  is  also  here  involved,  and 
painful  mental  states  predominate.  Despondency  and  gloom  issue  at 
limes  in  acute  melancholic  or  maniacal  outbursts,  yet  morbid  depression 
is  here  usually  associated  with  enfeebled  will  and  a  special  tendency  to 
instinctive,  impulsive  states.  Chronic  melancholia,  with  impulsive 
propensities,  is  the  prominent  mental  symptom.  The  disease  appears 
to  project  itself  mainly  upon  the  motorial  sphere  of  mind;  and  the 
diseased  vascular  tracts   in    the  cerebral    hemispheres  are  peculiarly 


408  THE    IXSAXTTY    OF   THE    SENTLE    EPOCH. 

prono  to  nppoar  in  the  frontal  and  motor  I'calms,  cortical  and  ganglionic. 
A  group  of  symptoms  constituted  by  despondency,  self-absorption, 
general  intellectual  torjjor,  failure  of  memory,  enfeebled  volition, 
impulsive  conduct,  often  desperately-suicidal  attempts;  and,  with  this, 
highly-chai-actcristic  physiognomical  signs,  such  as  a  pained,  vacant 
aspect,  a  dulled,  lustreless  eye,  a  jaundiced  earthy  tinge  of  integument, 
tortuous  radials,  temporals,  or  brachials,  a  slow  and  lalioured  utterance, 
and  an  utter  want  of  initiative — are  in  themselves  a  very  suggestive 
category.  When,  with  such  a  case,  we  find  general  muscular  enfeeble- 
ment  progressively  advancing,  a  history  of  slight,  transient  strokes,  a 
very  temporary  loss  of  speech,  a  slight  glossoplegia,  facial  or  brachial 
monoplegia,  or  slight  syncopal  or  vertiginous  attacks  repeating  them- 
selves frequently,  we  may  be  pretty  confident  that  we  have  to  deal  with 
a  case  of  chronic  cerebral  atrophy  as  the  result  of  vascular  disease,  and 
probably  associated  with  considerable  renal  and  cardiac  degeneration. 

Senile  Convulsions. — A  fourth  group  presents  itself  under  the 
form  of  convulsive  affections.  After  a  more  or  less  prolonged  period 
of  mania  or  melancholia,  the  persistence  of  which  may  be  unexplained, 
there  will  suddenly  occur  a  partial  or  general  convulsive  seizure,  with, 
or  without,  loss  of  consciousness.  The  patient  henceforth  becomes 
subject  to  more  or  less  periodic  attacks  of  genuine  epilepsy  or  epilepti- 
form convulsions.  Such  cases,  however,  are  not  so  numerous.  Out  of 
260  cases  of  senile  female  admissions  but  20  cases,  or  7*6  per  cent,  of 
the  whole,  were  subject  to  convulsive  attacks,  and  in  not  more  than 
one-half  this  proportion  did  the  convulsive  neurosis  assume  such  a 
grave  aspect  as  to  be  regarded  as  the  most  prominent  morbid  feature. 

Senile  Epilepsy  occurring  during  the  course  of  any  form  of  mental 
alienation  is,  of  course,  of  very  evil  augury.  It  betokens,  usiially,  a 
localised  nutritive  derangement  of  a  grave  character,  due  to  diseased 
vascular  tracts  of  the  cortex  or  ganglia  at  the  base. 

Senile  Dementia. — Lastly,  there  is  the  well-known  insane  dotage 
of  the  senile  dement,  in  which  all  the  mental  faculties  are  progressively 
affected,  and  in  which  maniacal  excitement,  or,  less  frequently,  melan- 
cholic gloom  or  agitation,  may  recur  over  and  over  again,  and  very 
vivid  hallucinatory  and  delusional  conditions  may  prevail;  yet  a  steady 
decadence  of  mind  proceeds  and  utter  fatuity  results. 

With  respect  to  the  question  of  inheritance  in  senile  subjects,  let  us 
remember  that  although  much  depends  on  the  organised  stability  of 
the  nervous-centres,  we  must  not  omit  to  lay  due  stress  upon  excep- 
tional environmental  conditions  of  life,  and  especially  \ipon  conditions 
self-induced,  or  to  which  the  organism  wilfully  exposes  itself  in 
defiance  of  all  physiological  dictates.  Whatever  be  the  resistance  of 
'  the  organism  to  morbid  excitants,  we  can  safely  assume  that  the  latter 


INCITIN-G   AND    PREDISPOSING   AGENCIES.  409 

may  reach  such  an  intensity  as  to  break  through  all  opposition,  and 
that  inherited  instability  need  by  no  means  be  predicted  in  such  cases; 
in  other  woi'ds,  insanity  may  be  acquired  purely  ab  extra.  "We  have 
too  many  instances  allbrded  us  of  the  break-down  of  good,  stable  minds 
through  the  stress  and  tension  induced  by  surrounding  conditions  of 
life,  to  permit  us  for  one  moment  to  hesitate  in  our  acceptance  of,  or  to 
allow  us  to  qualify,  this  statement.  Sustained  mental  exertion  may 
be  carried  on  under  unfavourable  circumstances  to  such  a  pitch  as  to 
issue  in  complete  demoralisation;  undue  stimulation  of  nervous-centres 
already  fagged  by  overwork,  will  as  certainly,  if  persisted  in,  entail  in 
the  issue  complete  disorganisation,  or  deterioration  of  the  output ;  it  is, 
therefore,  highly  necessary  that  we  should  lay  full  emphasis  upon  the 
environmental  conditions.  Given  a  case  of  strong  hereditary  predis- 
position, and  we  infer  that  slight  exciting  agencies  will  suffice  for  a 
culmination  in  some  morbid  development.  Given  but  a  feeble  predis- 
position, and  the  resistance  to  morbid  excitation  rises ;  so  that  a 
potent  cause  only  ah  extra  will  induce  the  vicious  evolution.  Yet  it  is 
equally  true  that,  apart  from  any  traceable  ancestral  frailty,  certain 
vicious  conditions  of  life  will  of  themselves  induce  such  cerebral 
disorder  as  to  culminate  in  an  attack  of  insanity.  What  do  "we  know 
respecting  ancestral  history  and  the  interaction  of  the  environment  in 
cases  of  senile  insanity  1 

A  predisposition  was  clearly  ascertained  in  some  58  cases  of  senile 
insanity  out  of  261  male  patients,  or  a  percentage  of  22.  This  estimate 
includes  collateral  and  direct  transmissions,  and  was  limited  almost 
exclusively  to  the  parentage  and  to  the  collateral  line  of  brothers  and 
sisters.  If  direct  inheritance  only  be  taken  into  account,  the  percentage 
would  still  remain  as  high  as  15.  Now  this  is  considerably  above  Dr. 
Clouston's  figure  (13  per  cent.),  and,  in  fact,  lies  midway  betwixt  the 
percentage  given  by  him*  and  the  average  heredity  ascertained  for 
1810  cases  of  all  forms  of  insanity  alike  (31-5  per  cent.).  Dr.  Clouston 
speaks  of  ancestral  inheritance  as  "-yery  uncommon"  but  admits  that 
such  estimate  includes  a  fallacy  "  that  the  facts  about  heredity  were 
further  back  and  more  forgotten  in  this  than  in  any  other  form.''! 
Such  a  qualification,  undoubtedly  well-based,  applies  equally  to  our 
own  statistics ;  and  we  may  with  justice  assume  that  an  insane  inheri- 
tance would,  if  all  the  facts  were  forthcoming,  be  found  to  be  pretty 
much  what  is  the  average  for  all  forms  of  insanity  taken  together. 

But  apart  from  the  frequency  of  its  occurrence  as  a  factor  is  the 
question  of  the  nature  of  such  inheritance  and  its  intensity ;  unfortun- 
ately our  data  for  a  reliable  conclusion  upon  these  points  are  too  scanty. 
Dr.  Clouston's  assumption  is  that — "  To  have  survived,  therefore,  the 

*  Op.  c'lt.,  p.  567.  i  IhkL,  p.  500. 


410 


THE    INSANITY    OF    THE    SENILE    EPOCH. 


changes  and  chances,  tlie  crises  and  perils  of  life  with  intact  mental  func- 
tion till  after  sixty,  means  slight  neurotic  heredity,  or  great  absence  of 
exciting  causes  of  disease."*  Were  we  to  regard  the  dictum  tliat  the 
stronger  predisposition  is  manifested  earlier  in  life  (open  as  it  is  to  such 
Tiumerous  excejitions)  we  would  still  take  exception  to  applying  such  a 
Jaw  to  the  cases  of  insanity  under  consideration.  What  are  the  positive 
facts  before  us  1  If  we  take  into  consideration  all  forms  of  neurotic  inheri- 
tance alike,  we  find  a  percentage  of  2G-4  give  such  histories;  that  in 
several  cases  both  father  and  mother  were  insane;  that  in  some,  several 
members  of  the  family  were  epileptic  ;  that  in  others,  direct  hereditary 
insanity  was  traceable  (associated  with  epilepsy  and  paralysis),  and  that 
.suicide  was  not  infrequent  in  the  family.  We  should,  therefore, 
incline  to  the  view  that  the  senile  insane  exhibit  a  fairly  average  pre- 
dis|)osition  to  insanity;  and  that,  possibly,  its  late  development  in  such 
.subjects  may  depend  upon  the  nature  of  the  neurotic  inheritance  and 
the  developmental  period  during  which  it  was  originally  acquired  by 
the  ancestor ;  for  the  law  that  a  morbid  condition  tends  to  reappear  at 
an  earlier  age  in  the  j^rogeny  is  not  final  upon  this  point.  For  us, 
however,  the  more  important  point  for  recognition  is  that  whatever 
proclivity  towards  insanity  there  be  in  such  subjects,  due  to  inheri- 
tance, there  is  a  most  powerful  agency  in  operation  in  a  large  number 
of  such  cases  in  the  surrounding  conditions  of  life.  Undue  cerebral 
■excitation,  whether  in  the  form  of  excessive  mental  work,  and  especially 
when  prolonged  intellectual  operations  are  associated  with  anxiety  and 
worry,  or  exhaustive  emotional  states,  frequent  exhaustive  demands 
upon  the  intellectual  operations,  sustained  mental  tension  in  the 
struggle  and  competition  for  existence,  will,  as  we  well  know,  result  in 
utter  mental  and  physical  prostration,  even  in  those  who  possess  the 
■elasticity  and  resistance  of  manhood ;  much  more  should  we  expect 
such  agencies  to  be  operative  for  ill,  at  an  age  when  the  brain-cells 
haA-e  reached  their  limit  of  normal  functional  activity,  when  function 
<leclines,  and  physiological  dissolution  commences,  in  the  series  of 
downward  retrogressive  changes  of  senility. 

Sucli  unwise  demands  made  on  the  nervous-centres  during  adult  life 
AVQ  prone  to  induce  premature  senility,  and  the  various  mental 
derangements  to  which  the  aged  are  subject ;  but  a  still  more  potent 
factor  is  comprised  in  the  association  with  these  conditions  of  alcoholic 
stimulation.  Excessive  alcoholic  indulgence  lends  a  frightful  impetus 
to  the  retrograde  changes  of  this  epoch,  tending  to  over-excitation  and 
exhaustion  of  the  nerve-cells  ;  to  retention  of  hydro-carbon  in  the 
system ;  to  vascular  paresis  and  disease  of  the  arterial  tunics ;  to 
universal  degradation  in  tyjie  of  tissue,  notably  of  the  nerve-centres : 

*/6ic/.,  p.  566. 


ALCOHOL    AND    SENILE    INSANITY,  411 

we  may,  indeed,   readily  appreciate  tlie  evil  effects  of  undue  mental 
exertion,  backed  up  by  alcoholic  stimulation. 

T.  G.,  aged  fifty-two,  married,  with  a  family  of  five  cliildren,  a  ininer  by  occu- 
pation. Patient  was  suffering  from  his  first  attack  of  insanity,  which  began  a 
month  ago.  He  was  a  short,  well-nourished  subject,  of  florid  complexion,  con- 
junctiva? tinged;  arcus  senilis  M^ell  marked;  pupils  equal  and  active;  slight 
iiattening  of  right  side  of  face;  tongue  protruded  straight,  slightly  tremulous. 
There  was  excessive  sensibility  of  the  soles  of  the  feet;  when  these  were  tickled, 
tlie  whole  body  was  thrown  into  a  convulsive  state.  He  had  formerly  been  addicted 
to  very  heavy  drinking,  although  more  abstemious  during  the  past  four  years.  His 
father  drank  to  excess,  and  was  a  "bad  character."  His  father's  sister  cut  her 
throat  at  this  asylum.  Patient's  two  sisters  (twins)  are  at  present  inmates  here. 
Mother  was  at  this  time  seventy-five  years  of  age,  strong  and  hale.  No  history  of 
cranial  injury. 

About  eleven  months  ago,  patient  had  noticed  convulsive  movements  of  both 
eyeballs  [nystagmus),  and,  subsequently,  jerking  movements  of  the  head  and  neck. 
He  sought  treatment  for  his  eyes  at  the  Leeds  Infirmary;  but,  whilst  there,  his 
limbs  suddenly  one  night  were  thrown  into  convulsive  movements  like  the  head. 
Such  movements  recur  frequently,  but  have  sometimes  left  him  completely  for 
a  week  together;  they  are  always  increased  during  emotional  states.  He  had 
gradually  lost  power  in  his  right  arm  and  leg;  and  speech  also  had  become  much 
impaired.  Childish  moods  were  then  noticed;  he  would  collect  worthless  rubbish, 
and,  if  deprived  of  it,  become  most  passionate  and  violent.  Memory  deteriorated, 
and  he  began  to  misname  his  acquaintances  and  relatives.  Great  irritability  was 
apparent  later  on;  he  would  violently  assault  little  children  without  obvious 
reason. 

A  fortnight  before  admission  he  had,  for  the  first  time,  a  succession  of  fits,  in 
which  ' '  his  eyes  were  drawn-up — he  frothed  much  at  the  mouth,  his  mouth  being 
dra^^Ti  to  one  side  (which  side  unknown) ;  his  limbs  were  much  jerked  about,  and 
he  remained  for  some  time  unconscious."  Had  sufi'ered  lately  from  aural  and 
visual  hallucinations;  accused  his  wife  of  being  unfaithful  to  him,  and  said, 
"people  make  a  fool  of  me."  He  had  threatened  his  wife  with  violence,  and  had 
said  he  would  cut  his  throat. 

He  was  emotional  upon  his  admission,  singing,  weeping,  and  rambling  alter- 
nately. He  was  then  obviously  suffering  from  ataxic  aphasia,  with  a  certain 
degree  of  amnesia.  "Asked  to  pronounce  a  certain  word,  he  frequently  repeats  the 
first  syllable  before  proceeding,  and  when  the  word  is  completed  successful^,  he 
is  apt  to  reiterate  the  whole  Avord  over  and  over  again,  or  interpolate  it  subse- 
quently into  a  sentence  wholly  irrelevant  and  foreign  to  it  in  context." 

"He  understands  all  that  is  said,  but  his  replies  are  frequently  quite  incom- 
prehensible ;  memory  is  notably  impaired,  and  consciousness  so  far  affected  that 
he  fails  to  recognise  where  he  is,  when  he  came,  or  the  nature  of  his  surromidings. 
He  shows  the  instantaneous  obliteration  of  memory  for  any  given  name  or  date  so 
characteristic  of  certain  alcoholics.*  He  still  evinces  distrust  of  his  wife,  and  is 
inclined  to  impute  to  her  all  his  troubles  and  present  physical  ailments.  Atten- 
tion is  commanded  with  fair  ease.  He  becomes  readily  emotional  and  agitated, 
when  his  breathing  is  accelerated,  and  choreic  movements  of  head  and  limbs 
supervene ;  locomotion  somewhat  impaired  by  the  jerkj'  naovements  of  his  limbs. " 

*  See  case  of  /.  F.,  and  of  M.  H.  L.,  pp.  310,  311. 


^12  THE    INSANITY    OF    THE    SENILE    EPOCH. 

Such  being  the  history  prior  to  and  upon  admission,  the  patient,  a  fortnight 
later,  had  several  recurrences  of  tlie  choreic  movements,  became  decidedly  suicidal, 
dashing  himself  Iiead  foremost  on  the  floor.  Three  months  later,  he  had  a  paralytic 
seizure  sudden  in  onset.  He  fell  on  his  knees ;  was  unconscious  for  a  short  time ; 
the  right  side  of  face  and  riglit  arm  showed  muscular  twitchings — the  eyes  turned 
to  the  right  side,  and  tlie  eyelids  were  convulsively  affected.  The  twitching  of 
the  right  arm  continued  long  after  return  of  consciousness ;  slight  right  hemiplegia 
was  present  the  following  day. 

For  several  weeks  he  continued  very  restless,  in  a  hea\'y,  stupid  state,  and 
evidently  much  demented ;  both  pupils  minutely  contracted.  The  lunbs  became 
more  enfeebled,  and  he  had  to  be  kept  in  bed. 

A  recurrence  of  the  convulsive  attacks  supervened  some  months  later,  and  after 
lying  for  a  few  days  in  a  semi-conscious  state  with  constant  twitcliings  of  the 
limbs,  and  a  high  temperature,  he  died. 

Sectio  cadav.  Skull-cap  symmetrical,  of  average  thickness  and  density ;  no  adhe- 
sion of  dura  mater.  Sinuses  contained  fluid  blood.  Arachnoid  opaque  over  frontal 
and  parietal  regions,  with  considerable  fluid  in  the  meshes  of  pia  mater,  which  Avas 
thick  and  tourjh,  but  strijjped  freely.  There  were  one  or  two  doubtful  patches  of 
adhesion  along  the  marginal  or  first  frontal  gyrus.  Vessels  at  base  were  very 
atheromatous.  There  was  great  wasting  of  gyri  in  the  frontal  and  parietal  regions, 
especially  on  the  left  side.  The  brain  tliroiighout  was  softer  than  normal,  and  of 
a  dirty,  rusty  hue.  The  grey  matter  Avas  shallow;  the  white  matter  studded 
with  very  niunerous  coarse  vessels,  showing  also  upon  section  small  patches 
of  a  imihish  tint.  No  special  focus  of  softenmg  was  noted.  Cerebellum  and  basal 
ganglia  presented  no  change. 

Whole  lirain     weighed  1270  grms.  Left  frontal  lobe  A^-eighed  198  grms. 

Eight  hemisphere  ,,         555      ,,  Cerebellum  ,,         167    ,, 

Left  ,,  „         515      „  Pons  „  20    ,, 

Right  frontal  lobe  ,,         327      ,,  Medulla  ,,  8    „ 

The  heart  weighed  355  grms.  ;  muscle  pale,  ill-nourished  ;  large  patches  of 
atheroma  at  base  of  aorta;  valves  healthy. 

Plight  lung,  955  grms. ;  intensely  engorged  throughout,  but  still  floated,  and 
on  pressure  crepitated ;  no  tubercle  or  inflammatory  induration. 

Left  hmg,  810  grms.;  adherent  by  old  fibrous  bands;  like  the  right  lung,  it 
was  engorged  throughout. 

Liver,  firmly  bound  to  diaphragm;  substance  firm  and  fibrous. 

Spleen,  163  grms. ;  congested  and  friable. 

Right  kidney,  140  grms. ;  left  kidney,  ISO  grms.  Capsules  were  adherent  in 
both  organs ;  the  surface  graniilar ;  the  sulistance  greatly  wasted  in  cortical 
and  pyramidal  jDortions ;  the  pelvis  of  the  right  kidney  was  dilated. 

Of  the  261  male  senile  cases,  as  many  as  75  (i.e.,  28-7  pci'  cent.)  were 
conclusively  proved  to  have  been  of  intemperate  habits  for  some  years 
prior  to  their  attack  of  insanity;  and  there  is  reason  for  regarding  this 
percentage  as  far  below  the  actual  truth.  Later  on,  we  shall  find  that 
alcohol  gives  a  special  direction  to  the  morbid  tendency,  having  a 
preponderating  influence  in  the  production  of  special  forms  of  senile 
psychoses.      Thus   senile   mania,   melancholia,   and   the   dementia   of 


PEODROMATA: — SYMPTOMS   AT   02ISET.  413 

chronic  cerebral  atrophy  eacli  afford  an  alcoholic  history  in  40  per 
cent. ;  whilst  amongst  the  senile  dements  proper,  this  factor  appears 
only  in  IG  per  cent. 

Onset  and  Prodromata. — Were  we  to  attempt  to  define  the 
boundary  betwixt  the  physiological  and  pathological  form  of  senility, 
between  the  ordinaiy  second  childishness  of  old  age,  and  the  dementia 
resulting  from  the  senile  atrophy  of  disease,  we  should  find  the  task 
a  difficult  if  not  an  impossible  one.  No  such  limit  exists ;  the  one 
form  passes  by  such  gradations  into  the  other,  that  it  is,  at  times, 
impossible  to  say  that  the  physiological  retrogression  has  been 
respected,  and  that  the  symptoms  imply  no  genuine  pathological 
change.  Cases  there  are  where  the  onset  of  senile  dementia  is  so 
marked,  or  so  sudden,  or  so  premature,  that  no  doubt  whatever  can 
be  entertained  that  the  physiological  barrier  has  been  overstepped ; 
yet,  in  most  instances,  the  atrophy  of  premature  senility,  at  its  onset, 
heralds  itself  by  very  uncertain  symptoms,  which  pass  by  insensible 
gi'adations  into  the  less  equivocal  character  of  the  fully-developed 
disease. 

Amongst  the  prodromal  signs  of  this  affection  are  an  uncertainty 
and  fickleness  of  disposition,  and  rajDid  changes  of  mood.  Moody 
taciturnity  alternates  with  fits  of  almost  childish  hilarity.  The 
patient  exhibits  unreasonable  irritability,  spasmodic  passion  upon 
trivial  occurrences,  intolerance  of  contradiction  or  restriction,  and 
impatience  of  former  pursuits.  Dr.  Anstie  has  drawn  attention  to  the 
irritable  perversity  of  early  stages.*  Hebetude  and  lassitude  are 
frequent  precursors  of  incipient  cerebral  atrophy ;  but,  the  more 
striking  feature  is  the  alternation  of  moods,  emotional  variability  and 
explosiveness.  Headache  is  often  a  prominent  symptom,  and  vascular 
turgescence  a  notable  feature ;  slight  exei'tion,  such  as  ascending  a  hill 
or  a  flight  of  stairs,  or  violent  laughter,  resulting  in  swollen  contorted 
veins  and  florid  face.  Then  arise  noticeable  defects  in  the  intellectual 
operations  due  to  occasional  lajose  of  memory,  very  occasional  and  very 
transient,  yet  anxiously  noted  by  watchful  friends.  Insomnia  at 
night  may  alternate  with  diurnal  hebetude,  lessened  activity  and 
languor. 

Symptoms. — Such  signs  are  of  ominous  portent  in  those  advanced 
in  years,  or  whose  former  mode  of  life  is  known  to  have  been  favour- 
able to  premature  senility.  An  attack  of  maniacal  excitement  may 
now  usher-in  unequivocal  signs  of  the  nutritional  impairment  of  the 
brain;  and  upon  its  subsidence,  well-marked  indications  of  enfeebled 
mind  appear. 

Similarly,    much    mental    depression   may    ensue,   and    melancholic 
*  See  Pdi/chological  Medicine,  Buckuill  and  Tuke,  p.  3i2. 


414  THE    INSANITY    OF    THE    SENILE    EPOCH. 

agitation  precede  the  more  profound  reductions  of  a  later  date.  In 
tlie  greater  number  of  cases,  however,  the  transition  is  a  gradual  one, 
from  the  prodromal  signs  indicative  of  failing  nutrition,  to  those  of 
functional  derangement  of  greater  gravity,  or  of  its  complete  arrest. 

The  failing  mental  powers  illustrate  the  law  of  dissolution,  whereby 
the  highest  and  last-evolved  members  of  a  series  fail  earliest.  The 
power  of  abstract  thought  suffers  early ;  complex  reasoning  becomes 
a  painful  effort;  mental  processes  generally  become  simple  and  more 
automatic.  Representative  states  are  less  vigorous,  and  association 
of  ideas  enfeebled ;  hence,  the  contrasting  faculties  of  the  mind  lose 
their  former  energy.  The  creative  operations  of  the  imaginative 
sphere  decline,  and  reverie  usurps  their  place  in  the  mental  life. 
The  higher  emotionaP  states  and  moral  sentiments  fail  to  affect  the 
mental  life  and  the  conduct  of  the  individual  with  the  vigour  of 
former  days;  and,  in 'fact,  the  possible  adaptations  of  the  organism 
are  far  less  complicated  and  its  envii'onmental  horizon  is  correspond- 
ingly limited.  This  may  ;dl  be  true,  and  yet  memory  may  not  be 
greatly  affected ;  sooner  or  later,  however,  this  faculty  declines,  and, 
as  has  been  frequently  observed,  the  failure  is  chiefly  as  respects 
recent  events,  the  viore  remote  events  of  the  history  being  recalled 
vividly  and  accurately.  We  do  not  here  recognise  the  instantaneous 
loss  of  impressions  referred  to  in  alcoholic  cases;  it  is  not  a  feature  in 
senile  insanity  apart  from  alcoholism ;  yet,  that  there  is  greatly 
diminished  impressibility  in  senile  dementia  is  nevertheless  true.  The 
characteristic  senile  memory,  the  diminished  revivability  of  recent 
impressions  as  compared  with  more  organised  ones,  betrays  itself  in 
the  whole  tenor  of  the  patient's  life  henceforth ;  he  lives  his  child- 
hood's days  over  again ;  recent  impressions  have  but  a  transient  and 
faint  influence  upon;^his  ideation — or  they  fuse  with  the  more  vivid 
series  of  older  and  more  remote  states  of  feeling;  a  dreamy  reverie 
takes  the  place  of  vigorous  perceptive  processes ;  bygone  events  appear 
transformed  into  existent  realities,  and  are  blended  and  confused  with 
the  passing  events  of  the  moment.  Localisation  in  time  and  space 
will  eventually  be  impossible,  and  complete  incoherence  of  thought 
will  ensue.  Although  this  law  of  dissolution  is  invariably  exemplified 
in  senile  dementia,  it  is  remarkable  that  at  times  we  are  surprised  to 
find,  even  in  cases  of  profound  enfeeblement  of  memory,  a  transient 
gleam  of  intelligence — the  recognition  of  a  series  of  perfectly  recent 
impressions  in  their  natural  connection — when  we  had  supposed  the 
subject  was  completely  oblivious  to  such  circumstances.  This  seems 
only  explicable  on  the  assumption  that  the  law  of  trivial  association 
will  bring  together  the  recent  impressions  of  the  moment  in  relation 
to  the  more  deeply-organised  states  of  the  past ;  and  that  the  more 


NATURE    OF    THE    SENILE    REDUCTIONS.  415 

deeply-organised  are  the  states  with  whicli  such  recent  impressions  are- 
associated,  the  more  recoverable  such  states  of  consciousness  are  and 
the  more  resistant  to  morbid  influences. 

Now  follows  a  greater  or  less  blunting  of  the  special  senses;  deaf- 
ness is  a  common  symptom ;  there  is  also  slowed  nervous  conduction 
and  a  sluggish  reaction.  The  expreSSive  faculties  suffer  likewise 
with  the  impressive  sphere ;  not  only  is  the  subject  less  recipient 
and  impressionable^  but  he  is  also  less  reactive.  The  intelligent 
initiative  is  rarely  assumed ;  all  actions  are  more  instinctive,  auto- 
matic, and  impulsive;  speech  is  hesitating,  slowed,  and  highly  charac- 
teristic— not  only  as  the  result  of  dementia,  but  also  because  the 
tongue  has  lost  its  cunning  and  is  less  glib ;  there  is  a  dislike  for  any 
mental  effort  from  the  outset,  and  eventually  an  utter  inability  for 
sustained  concentration  of  the  mind  on  any  one  subject ;  there  is  an 
equal  distaste  for  'physical  exertion.  Reduced  to  an  automaton,  in, 
every  sense  of  the  word,  his  habits  of  life  are  simple  in  the  extreme ; 
and  all  his  feelings,  thoughts,  and  utterances  savour  of  sameness  and 
repetition.  Of  all  the  insane  the  senile  dement  is  the  one  whose 
habits  of  life  are  most  stereotyped,  and  whose  actions  generally 
and  speech  are  least  variable  and,  therefore,  most  predicable. 

In  the  dissolution  of  his  nervous  organisation  the  doubly-compounded 
rhythmic  actions  of  an  elaborate  nervous  mechanism  appear  to  have 
given  place  to  the  simpler  rhythms  regulating  the  activities  of  simpler 
forms  of  life.  The  physical  signs  of  senile  decrepitude  are  notably 
marked ;  they  are  those  of  almost  universal  atrophy.  Exceptional 
cases  occur  where  obesity  prevails ;  but  the  rule  is  that  all  the  tissues, 
viscera  (except  heart  and  kidney),  and  glands  undergo  excessive 
atrophy,  often  pi'eceded  by  fatty  degenerative  change.  It  is  scarcely 
necessary  to  more  than  recall  the  thin  harsh  skin ;  the  wrinkled  face  ; 
edentulous  jaws;  the  senile  arcus ;  the  grey  hair  and  bald  pate  witli 
its  glossy  atrophic  integument ;  the  tortuous  corded  temporals  or 
radials ;  the  diminished  stature  and  weight ;  the  skinny,  shrunken, 
extremities  ;  evident  emaciation,  muscular  enfeeblement,  and  wasting ; 
stooping  attitude  and  tottering  gait. 

It  must  not  be  supposed  that  the  mental  decadence  here  sketched- 
out  takes  place  without  emotional  stoi-ms  ;  for  wild  gusts  of  excitement 
sweep  over  the  scene  repeatedly  during  the  progi'ess  of  the  cerebral 
atrophy.  Such  maniacal  attacks  are  often  most  persistent  and  most 
obstinate  to  treatment.  In  fact,  the  recurrent  maniacal  attacks  of  senile 
insanity  during  the  progress  of  cerebral  atrophy  are  the  least  amen- 
able to  treatment  of  all  forms  of  mania.  The  long  continuance  of  such 
excitement,  the  deprivation  of  sleep,  and  incessant  restlessness,  is  often 
a  source  of  surprise  to  the  student  of  insanity,  who  would  a  priori 


41 G  THE    LSSAXITY    OF   TUE   SEXILE    EPOCH. 

anticipate  rapid  exhaustion  as  the  natural  outcome.  Such  cases 
naturally  cause  much  anxiety  and  trouble  to  their  guardians,  but  this 
anxiety  is  largely  amplified  by  their  occasional  refusal  of  food,  and 
obstinate  resistance  to  compulsory  feeding.  The  maniacal  outbursts 
of  these  senile  dements  is  often  revolting  from  their  degraded  habits 
and  utter  disregard  of  all  decency.  They  are  filthy  in  the  extreme ; 
they  are  also  destructive,  and  are  continually  removing  their  clothes 
and  exposing  themselves.  A  sexual  element,  also,  is  often  a  prominent 
feature  in  such  subjects;  erotic  tendencies  being  by  no  means  in- 
frequent during  such  maniacal  attacks.  Thus  it  is  that  at  the  onset  of 
senile  insanity,  ere  other  well-pronounced  symptoms  declare  them- 
selves, the  subject  (formerly  a  most  moral  and  well-conducted  man) 
suddenly  exhibits  such  erotic  tendencies,  outrages  every  sense  of 
decency,  and  brings  disgrace  upon  himself  and  connections,  ere  it  is 
discovered  that  he  is  an  iri'esponsible  agent. 

This  objectionable  tendency  is  one  strong  reason  why  an  aged 
parent,  suifei'ing  from  such  maniacal  outbursts,  should  be  removed 
from  the  care  of  his  family.  Occasionally  such  outbursts  of  excite- 
ment alternate  with  depression,  and  the  following  instance  of  senile 
hypochondriasis  illustrates  this  well : — 

J.  A.,  aged  sixty -two,  widower,  a  labourer;  a  man  of  average  height  and  well- 
nourished,  with  a  bullet-shaped  head,  light  saudy-coloured  hair,  and  blue  eyes. 
Patient  had  lived  a  steady  temperate  life  ;  had  suffered  from  no  special  illnesses — 
*'  stroke  "  or  "fit."  Had  sustained  no  injury  to  the  head.  Family  history  was  not 
ascertainable.  He  had  been  wretchedly  depressed  for  six  months  ;  but  for  three 
years  preceding  his  admission,  he  had  suffered  from  slight  attacks  of  depression 
alternating  with  excitement,  and  was  taken  charge  of  in  the  workhouse  iufii'mary- 
wards.  Six  mouths  since,  whilst  in  a  very  dejected  state  of  mind,  he  sprang  over 
a  bridge  uito  the  river,  but  was  rescued  and  taken  to  the  workhouse,  where  he  has 
remained  employing  himself  at  useful  occupations,  but  always  depressed.  After  an 
exciting  religious  service  which  he  attended  six  weeks  prior  to  his  arrival  at  the 
asylum,  he  became  terribly  dejected,  and,  at  times,  acutely  melaacholic,  rushing 
about,  wringing  his  hands,  and  crying  out  "lost,  lost,"  and  tried  eventually  to 
leap  from  a  window.  He  was  brought  to  the  asylum  in  a  state  of  great  agitation, 
struggling  -wildly,  and  necessitatmg  restraint  during  the  transit.  The  excitement 
abated  shortly  afterwards  ;  he  took  a  hearty  meal  and  slept  well.  The  next  morn- 
ing he  was  able  to  converse  calmly,  and  gave  a  detailed  account  of  his  past  life. 
"For  some  years  past  he  has  been  subject  to  i)eriods  of  'confusion  of  thouglit,'  and 
failure  of  memory ;  it  comes  on  snddenbj,  unexpeciedhj,  and  at  such  times  he  is 
wholly  incapacitated  for  work.  At  tunes  such  attacks  were  prolonged  and  accom- 
panied by  intense  depression,  during  which  he  had  to  be  placed  imdcr  supervision. 
In  one  of  these  fits  of  despondency  he  attempted  suicide.  He  beheves  he  is 
'eternally  lost;'  but  his  chief  trouble  at  this  time  was  not  so  much  liia  soul's 
welfare,  as  the  idea  that  he  cannot  digest  his  food  ;  he  constantly  dwells  upon  the  . 
condition  of  his  stomach  and  bowels,  to  which  he  refers  many  imaginary  ailments." 
His  memory  was  but  slightly  impaired,  being  more  sluggish  of  recall  than  actually 
deflective;  hia  intellectual  operations  geucxally  were  torpid;  his  attention  enfeebled. 


SENILE    HYPOCHONDRIASIS — SENILE    ATROPHY    AND    THROMBOSIS.    417 

SO  that  occasional  confusion  of  ideas  occurred  during  conversation ;  no  hallucina- 
tions existed.  He  had  a  dejected  expression.  The  x'^pils  were  equal  and  active, 
of  normal  size ;  the  tongue  was  protruded  straight,  and  showed  no  ataxy  or 
tremor.  No  evident  degeneration  of  the  superlicial  arteries  was  indicated,  and 
the  heart  was  apparently  healthy. 

Patient  at  the  asylum  soon  settled  down  to  suitable  occupations,  but  alwa3'S 
wore  a  depressed  and  anxious  expression  ;  and  was  eager  to  talk  of  his  hypochon- 
driacal fancies.  His  memory  for  recent  events  underwent  notable  enfeeblemcnt, 
and  his  speech  was  slow  and  laboured.  Suddenly  he  became  acutely  melancholic, 
betrayed  extreme  agitation,  labouring  under  the  delusion  that  he  was  lost,  but  he 
resumed  his  former  state  in  a  few  days.  Eighteen  months  after  admission,  it  is 
noted  that  "he  is  habitually  dejected,  groans  at  times,  observes  that  nervous 
debility  has  affected  his  mind ;  he  sleeps  badly  and  his  health  is  feeble."  Dur- 
ing the  following  year  he  continued  more  agitated,  his  melancholic  delusions  gaining 
a  tirmer  hold  upon  him.  He  affirmed  that  "  the  influence  is  on  him,  and  will  blow 
him  to  atoms;"  that  "his  inside  is  flushed  up  to  his  throat;"  that  "there  is  a  fire 
within  his  body;"  that  his  food  has  "never  digested  since  he  came  here,"  and  that 
his  "bowels  are  obstructed."  Chloral  alone  afforded  him  relief,  and  was  frequently 
required  to  secixre  sleep.  Thus  he  remained  for  some  years  with  no  relief  nor  altera- 
tion of  his  deluded  state,  pacing  up  and  down  the  wards  with  woe-begone  aspect, 
groanmg,  importunate  upon  the  subject  of  his  hypochondriacal  fancies;  dwelling 
upon  his  "depressed  spirits,"  "sleeplessness,"  and  " the  fire  that  has  for  twenty 
years  burned  within  him."  He  died,  seven  years  after  admission,  of  pulmonary 
congestion. 

Many  cases  of  senile  dementia  present  for  some  time  a  gradual, 
progressive  mental  enfeeblement,  without  any  notable  degree  of  excite- 
ment. A  constant  unrest,  a  mild  depression,  with  very  vague  fears 
and  ill-defined  notions  of  coming  trouble  prevail,  often  associated  with 
distrust  and  more  definite  suspicions  of  persecution.  Such  was  the 
following  case,  in  which  the  ideas  of  persecution  became  more  defined, 
and  issued  in  paroxysms  of  great  agitation;  and  in  which  the  progress  of 
atheromatous,  vascular  disease  resulted  in  a  slight  transitory  mono- 
plegia from  plugging  of  the  vessels. 

I.  B.,  a  widow,  aged  seventy-five.  Lost  her  husband  eight  years  ago,  and  lived 
with  her  children  until  removed  to  the  workhouse,  nine  weeks  since,  having  become 
unmanageable  at  home.  She  had  been  failing  in  mental  powers  for  some  few  years. 
.  At  this  time  she  was  excited  and  very  restless,  wandering  about  her  room  day  and 
night,  seeking  her  husband,  whom  she  believed  still  lived,  and  expressuig  fears  that 
the  inmates  of  the  workhouse  had  designs  upon  her  life.  Her  habits  as  regards 
alcohol  had  been  temperate  ;  there  was  no  history  of  insanity  or  other  neurosis  in 
her  antecedents.  Upon  admission  she  was  fairly  quiet,  and  conversed  affably. 
Grave  mental  failure  was  apparent ;  she  still  thought  she  was  at  the  -SA-orkhouse, 
although  she  had  been  here  a  week ;  "came  direct  from  her  own  home,  where  she 
had  been  living  with  her  husband  and  mother-in-law ;  the  latter  is  not  old,  and 
she  speaks  of  her  husband  as  youthful;  she  herself  is  about  thirty-six  years  of  age; 
her  husband  lives  in  Kew  Leeds;  she  saw  him  a  fortnight  ago."  "She  makes  vague 
statements  of  ill-treatment  before  coming  here,  weeps  childishly,  and  then  as 
suddenly  becomes  cliccrful  and  contented.     She  is  a  shrunken  old  woman,  mucli 


418  THE    INSANITY    OF   THE    SENILE    EPOCH. 

reduced  in  bodily  condition  ;  the  face  much  wrinkled,  the  complexion  earthy,  and 
the  hair  grey  and  scanty  ;  there  are  no  teeth.  The  superficial  arteries  show  no 
marked  signs  of  degeneration  ;  the  jailse  is  90,  regular  and  of  fair  strength  ;  no 
obvious  morbid  state  of  circulatory  or  respiratory  systems  appreciable  ;  urine 
almost  colourless ;  specific  gravity,  1010 ;  no  trace  of  albumeu  ;  no  deposits."  During 
her  first  mouth's  residence  here  she  exhibited  the  usual  reductions  of  the  senile 
dement,  but  no  outbursts  of  excitement  occurred.  She  slept  soundly  and  took  her 
food  heartily,  yet  she  was  restless,  discontented,  peevish,  wandered  about  in  an 
aimless,  half-vacant  manner,  and,  when  questioned,  explained  that  her  husband 
was  at  work  close  by  at  a  colliery,  and  that  she  sought  him  and  her  son.  Her 
habits  also  were  inattentive  ;  did  not  recognise  the  nature  of  her  surroundings ; 
believed  she  was  still  at  Clayton  Workhouse.  About  four  weeks  after  admission 
she  had  one  of  the  characteristic  seizures  to  which  these  aged  dements  are  subject. 
Whilst  sitting  in  her  chair  she  became  pale  and  faint,  lost  consciousness  moment- 
arily, and  the  left  upper  extremity  was  found  paralysed.  The  patient  remained  in 
a  state  of  semi-stupor  for  about  an  hour,  then  recovered  rapidly,  and  shortly 
afterwards  could  walk  about  readily;  the  paralysed  limb  regained  its  usual  power. 
A  month  later  it  is  noted  that  "she  fancies  her  father  lives  here,  as  also  that  his  age 
and  her  own  are  the  same.  Is  dirty,  restless  ;  often  weeps  and  cries  to  go  home  ; 
is  more  feeble  and  wasted."  Still  later  on  she  became  melancholic,  even  acutely  so ; 
appeared  in  great  agitation  and  terrified  ;  would  cry  aloud,  "  Are  you  going  to  pub 
me  underground? " 

The  following  case  i.s  one  of  a  more  acute  character ;  the  prevailing 
mental  state  being  that  of  melancholic  depression,  attaining  at  times  a 
degree  of  acute  melancholia.  It  will  be  noted  how  the  physical  exam- 
ination testifies  to  the  general  malnutrition,  great  emaciation,  and  to 
the  failure  in  cardiac  energy  and  advance  of  atheromatous  change  in. 
the  peripheral  blood-vessels.  The  most  striking  feature  in  this  case  is 
the  hypochondriacal  state,  which  is  not  at  all  unusual  in  the  acute 
forms  of  senile  insanity  ;  hideous  delusions  being  entertained  as  to  the 
sinister  intention  of  those  with  whom  the  patient  is  brought  in  contact. 
The  rapid  cardiac  failure  often  leads  to  alarming  syncopal  attacks. 

H.  D.,  aged  sixty-two,  and  married.  A  somewhat  tall  woman  of  very  haggard, 
wasted  aspect;  the  complexion  sallow,  and  condition  generally  very  anaemic. 
Physical  examination  betrayed  enfeebled  cardiac  energy ;  the  impulse  exceedingly 
weak,  the  sounds  at  base  less  clear  and  sharp  than  normal,  but  there  was  no 
murmur.  The  temporal  and  radial  vessels  were  somewhat  hard  and  incompressible, 
but  not  tortuous;  pulse  96,  very  small  aud  feeble.  The  abdomen  was  shrunken 
and  hepatic  dullness  much  diminished.  Urine  1020,  slightly  cloudy,  anibcr-coloured, 
alkaline ;  a  trace  of  albumen ;  a  large  deposit  of  mucus.  The  patient,  on  admission, 
was  very  restless  and  maniacal— suddenly  springing  out  of  bed,  knocking  over  the 
buckets  of  water  used  by  the  scrubbers,  and  upsetting  the  patients'  food,  declaring 
it  to  be  poisoned.  She  made  strenuous  efforts  to  escape  from  her  ward,  refused  her 
food,  asserting  that  her  body  was  "  full  up,"  aud  there  was  no  room  in  her  stomach 
for  food.  After  a  restless  night  she  was  found  vei-y  melancholic,  and  the  subject  of 
hypochondriacal  delusions.  Thus,  she  stated  that  for  two  years  past  debility  and 
loss  of  appetite  had  prevailed,  and  she  had  now  discovered  that  her  spine  had 


ACUTE   SENILE    MELANCHOLIA.  419 

grown  forward  so  as  to  encroach  upoa  her  stomach,  jjreventing  the  entrance  of  food; 
her  bones  had  grown  longer  and  thinner,  owing  to  a  poison  in  the  water  in  which 
she  bathed  herself.  "She  affirms  that  stars  appear  in  tlie  room,  talks  childishly, 
and  falls  into  a  doze.  Hallucinations  of  hearing  prevail  at  times;  she  hears  the 
voices  of  thronging  multitudes  who  have  come  to  watch  her.  She  declares 
that  the  flesh  has  been  taken  off  her  bones  by  some  agent  introduced  into  her  bath, 
and  that  she  cannot  sit,  stand,  or  walk;  wishes  to  be  hanged."  Her  memory  was 
enfeebled,  especially  respecting  recent  events,  and  a  week  after  admission  she 
thought  she  was  in  the  Women's  and  Children's  Hospital,  and  had  been  here  two 
days.  A  few  days  later  she  expressed  fears  of  being  sent  away,  and  upon  being 
questioned,  admitted  that  she  believed  she  was  to  be  cut  up  by  the  butcher.  Was 
sleepless  and  restless,  talking  all  night.  Made  such  remarks  as — "Don't  put  my 
eyes  out ;  are  you  going  to  blind  me?  are  you  going  to  make  me  deaf?  "  Occasion- 
ally her  melancholic  fears  so  got  the  better  of  her  at  night  that  she  could  not  be 
kept  in  association  with  others ;  but  had  to  be  removed  to  a  single  room,  and  a 
small  dose  of  chloral  administered  ;  cried  out  in  terrified  tones — "  Don't  do  it  to- 
night, will  you  ?  What  are  you  going  to  do  ?  you  have  done  it  long  since,  haven't 
you  ? "  Her  habits  were  now  very  degraded.  A  month  after  admission  she  had  a. 
severe  syncopal  attack,  remained  very  pale  and  subconscious  for  some  time,  and  the 
pidse  became  extremely  feeble.  The  base  of  the  right  lung  now  presented  signs  of 
pueumouic  consolidation  ;  and  two  days  later  it  is  noted — "Pvequires  feeding  by 
the  funnel  with  every  meal ;  is  talkative ;  asks.  What  are  you  going  to  do  with 
me  ?  Ghastly  pallor  and  emaciation  are  present ;  she  becomes  partly  syncopal  in 
the  erect  posture  ;  there  is  friction-sound  at  base  of  right  lung  in  front ;  over  the 
basal  two  inches  of  this  lung  posteriorly,  percussion  is  dull,  and  there  is  high-pitched 
bronchial  breathing  with  sonorous  rhonchi ;  there  is  cough  with  purulent  expecto- 
ration. Ordered  rffff^Ji  grain  atropine  hypodermically  ;  is  fed  with  milk,  eggs,  and 
mutton-broth."  She  sank  into  a  state  of  coma  in  a  little  over  a  month  from 
admission,  and  died. 

As  an  instance  of  senile  insanity,  with  the  prevalence  of  mental 
exaltation,  the  case  of  J/.  H.  (p.  424)  may  be  usefully  contrasted 
with  the  above. 

The  mental  exaltation  here  alluded  to  is  one  of  gravest  moment 
and  ominous  of  coming  dissolution ;  the  genei'al  exaltation,  which  is 
the  prevalent  feature  in  all  simple  maniacal  states,  is  but  the  expression 
of  a  very  universal  disorder  of  function.  It  is  the  partial  exaltation 
manifested  as  regai-ds  one  or  other  of  the  most  complex  groups  of  feel- 
ings which  comprise  the  pesthetic  or  the  religious  sentiments,  the  social 
and  the  domestic  feelings,  the  sentiments  of  possession,  of  freedom,  and 
many  others — the  later  developments  of  civilised  man — it  is  this  exal- 
tation which  is  so  ominous  of  coming  evil.  The  sentiments  are,  as  ex- 
pressed by  H.  Spencer,  purely  re-representative  feelings;  a  compounded 
aggregate  of  numerous  recollections,  vague  yet  massive,  combined 
with  a  still  vaguer  part,  a  kindred  feeling  organically  associated  by 
ancestral  experience.*  Such  optimism  is  usually  the  knell  of  com- 
mencing decay.  We  need  not  here  attempt  to  analyse  such  complex 
groups;  we  need  only  recall  the  foct  that  according  to  the  special  group 
*  Principles  of  Psychology,  vol.  ii.,  p.  57S. 


420  TIIK    IXSANITY    OF    THE    SICNILK    EPOCH. 

we  ai'e  dealing  with,  there  will  he  more  or  less  of  the  emotional 
or  of  the  intellectual  constituent ;  that  the  higher  the  developmental 
phase  such  feelings  have  attained,  the  more  closely  will  the  emotional 
and  intellectual  factors  be  interblended,  and,  therefore,  the  less  dis- 
tinguishable inter  se;  and  the  more  prepondei'ating  will  be  the  cognitivfe 
elements.  The  cognitive  element  is  the  relational ;  for  thought  is  but 
the  passage  from  one  state  of  consciousness  to  another ;  it  is,  in  itself, 
but  a,  feeling,  which  is  of  insignificant  duration,  as  compai-ed  with  that 
of  the  states  of  consciousness  which  it  connects.  In  the  sudden  transi- 
tion from  one  state  to  another,  we  get  a  more  pronounced  relationship  ; 
the  cognitive  element  becomes  more  emjohasised,  and  thought  more 
definite.  Hence,  the  import  of  the  fact  that  the  relational  element  of 
mind  is  the  first  to  succumb  to  mental  disease.  If,  as  may  well  be 
conceded,  the  change  in  the  nerve-cell  represents  the  physical  basis  of 
conscious  states,  and  its  protoplasmic  extensions  represent  the  relational 
nexus  between  cell  and  cell,  whereby  a  change  from  one  state  to  another 
is  rendered  possible,  then  our  statement  is  tantamount  to  affirming 
that  there  is  a  failure  in  the  forcing  of  the  relational  channels — that  a 
greater  conscious  effort  is  required  for  definite  thought,  and  that, 
consequently,  there  occurs  the  intensified  feeling  which  we  have  already 
alluded  to  as  a  rise  in  subject-consciousness,  with  a  corresponding  fall  in 
object-consciousness.  This  rise  in  the  feeling  element,  and  failure  in 
the  cognitive,  leads  readily  to  a  delusional  state,  as  might  be  antici- 
pated. This  failure  in  the  relational  element  of  mind,  due  to  some 
physical  interruption  of  the  molecular  wave  which  traverses  the  con- 
necting links  between  cell  and  cell,  may  pertain  almost  exclusively  to 
certain  of  the  higher  evolved  groups  of  feelings,  and,  so  to  speak,  may  (by 
a  species  of  morbid  dissection)  issue  in  their  gi*adual  dissolution,  while 
the  other  faculties  remain  more  or  less  intact.  The  confusion  of  ideas, 
the  delusional  perversions,  the  indefiniteness  of  thought,  accompanying 
the  decay  of  the  cognitive  element,  proceed  pari  imssu  with  the  rise 
in  the  feeling  element  (as  exemplified  in  the  monomania  of  pride,  in 
the  delusional  states  of  general  paralysis,  and  in  the  monomaniacal 
states  of  masturbatic  insanity),  and  appear  to  indicate  territorial 
implications  of  mind,  possibly  due  to  vascular  changes.  Here  the 
question  naturally  arises  how  far  this  derangement  is  to  be  attributed 
to  physical  change  within  the  nerve-fibre,  or  how  for  to  interference  by 
extraneous  agencies,  such  as  vasomotor  changes,  kc.  The  nervous 
wave  which  pervades  the  labyrinth  of  cell  and  fibre-network  during 
active  functionising,  is  normally  determined  thither  by  the  act  of 
attention ;  and,  however  we  may  explain  this  faculty  (probably  due  to 
the  establishment  of  a  more  i-apid  and  vigorous  circulation  through 
the  active  area),  its  operation  doubtless  serves  to  intensify  the  in- 


*  DELUSIONS    OP    TUE    SENILE    AND    MONOMANIACAL    SUBJECT.  421 

tcllcctual  or  cognitive  element  of  mind,  and  the  relations  Ijetween 
feeling  and  feeling  become  more  pronounced  and  definite  ;  or,  in  other 
words,  thought  is  intensified.  On  the  other  hand,  its  failure  not  only 
reduces  the  nervous  wave  in  volume  and  in  vigour,  but  the  relational 
lines  cannot  be  forced  thereby,  and  hence  will  ensue  the  states  of  mind 
already  alluded  to.  Failure  of  attention  is  indubitably  the  earliest 
symptom  in  these  states  of  partial  exaltation.  From  this  point  of 
view,  the  failure  of  attention  is  the  primary  derangement,  and  the 
moi'bid  result  contrasts  notably  with  that  morbid  entity  engendered 
ab  extra.  If  the  bodily  sensations  (the  coensesthesis)  are  seriously 
deranged;  if  altogether  novel  and  obscure  sensations  are  aroused  by 
e.g.,  various  visceral  affections,  it  is  notable  that  the  personality  may  be 
endangered  thereby,  and  a  transformation  of  the  ego  may  result.  This 
fundamental  change  may  be  induced  by  the  'p&^'sistent  attention  given  to 
these  morbid  feelings  so  aroused — feelings  which  embrace  both  the  purely 
sensuous  and  cognitive  elements — and  overbalance  previously-existing 
states,  destroy  the  normal  contrast,  and  become  by  this  very  faculty  of 
attention  intensified,  and  thus  a  morbid  group  of  feelings  is  created  and 
consolidated,  which  stands  out  in  antagonism  to  the  old  self  as  a  new  ego. 
If  sensory  channels  become  the  media  for  the  transmission  inwards  to 
the  sensorium  of  molecular  Avaves  of  abnormal  force,  volume,  or  fre- 
quency, they  will  naturally  arouse  the  sentinel  faculty  of  attention  to 
question  their  nature  and  relationship,  and  thus  further  aid  the  forcing 
of  those  relational  lines  which  consolidate  the  whole.  We  have  thus  the 
possibility  in  the  nervous  mechanism  of  two  morbid  conditions  arising, 
wholly  distinct  in  character,  whereby  serious  intellectual  derangements 
may  ensue.  In  old  physiological  parlance  we  may  liken  them  to  the 
vis  afronte  and  vis  a  tergo  of  circulatory  phenomena;  the  former,  repre- 
sented by  the  faculty  of  attention,  the  latter,  by  the  varying  in-going 
currents  along  the  sensory  nerves.  When  the  morbid  transformation 
of  the  ccencestJiesis  gives  rise  to  the  gradual  pervading  of  the  old  by  the 
new  ego  {e.g.,  extreme  egoism  of  puberty) — as  the  strengthening  and 
elaborating,  and  integrating  process  advances  under  the  auspices  of  a 
restricted  attention — the  definiteness  of  the  delusional  concept  becomes 
notable,  and  no  possibility  of  scepticism  can  arise  ;  there  is  no  excite- 
ment, but  great  mental  calm. 

Hence,  the  essence  of  these  forms  of  monomania  is  their  con- 
structive nature,  whilst  the  distinctive  feature  of  the  perversions  of 
the  exalted  senile  dement  is  their  dissolution  ;  one  is  synthetic,  the 
other  analytic  and  destPUCtive.  Enfeeblement  of  the  faculty  of 
attention,  therefore,  evokes  failure  of  the  relational  element  of  mind. 
Thought  becomes  obscured,  and  lessened  in  vigour  and  definiteness, 
the  faculty  of  association  of  ideas  is  necessarily  weakened  ;  feelings  are 


422  THE    INSANITY    OF    THE    SENILE    EPOCH. 

more  crude,  ill-defined,  or  poorly-demarcated  from  associated  feelings  ; 
thought  becomes  less  coherent,  delusional  concepts  are  apt  to  arise 
from  exaggerated  feelings,  and  loss  of  the  contrasting  and  representative 
faculty,  and  excitement  prevails.  In  the  rapid  reductions  of  general 
paralysis  we  shall  see  how  all  those  feelings  which  are  based  upon  tho 
instincts  of  conservation  of  the  self,  or  of  the  progeny  (together  witli 
the  complex  and  consolidated  groups  making  up  the  social,  religious 
and  aesthetic  sentiments)  successively  become  deranged  ;  and  how  in 
each  the  faculty  of  attention  is  first  or  earliest  involved.  This  disease 
reproduces,  in  a  terribly-rapid  sequence,  the  morbid  results  which  more 
gradually  ensue  in  the  decay  of  senile  atrophy ;  the  relational  element 
or  the  nerve-cell  prolongation  is  the  earliest  to  succumb. 

Sonile  Amnesia. — We  have  already  seen  that  the  earliest  symptom 
apprising  us  of  commencing  decadence  of  mind  in  senility  is  the  failure 
of  memory  for  recent  occurrences.  The  latest  impressions  reaching  the 
sensorium  may  be  so  imperfectly  registered  as  to  be  rapidly  obliterated, 
or  they  may  fail  to  establish  the  organic  connections  whereby  they 
become  more  permanent  constituents  of  the  nervous  mechanism.  In 
the  nexus  of  processes  connected  with,  and  extending  around,  a  nerve- 
cell,  we  decipher  the  integration  of  structure  u])on  which  its  permanence 
as  a  functional  unit  depends  ;  and  the  more  free  such  channels  of  com- 
munication become,  the  more  fully  organised  is  the  structure,  and  the 
more  stable  and  resistant  to  the  enci'oachments  of  senile  dissolutions. 
The  latest  requirements,  however,  are  expressed  in  the  structural  modi- 
fications of  the  highest  nervous  arrangements  where  integration  of 
structure  is  least  advanced  ;  and  unlike  those  associations  which  have 
been  called  into  activity  over  and  over  again,  many  thousand  times, 
they  fail  in  that  nexus  of  communications  necessary  to  their  stability. 
Thus  it  becomes  a  matter  of  common  observation  that  these  senile  sub- 
jects are  oblivious  to  the  most  ordinary  events  occurring  in  their 
immediate  presence ;  they  will  sit  down  and  enjoy  a  hearty  meal,  and 
an  hour  after  be  unconscious  of  the  fact;  will  meet  a  friend  in  converse, 
and  forget  immediately  both  the  occurrence  and  the  conversation.  If 
the  event  be  recalled,  its  connections  with  his  recent  experiences  are 
so  frail  as  to  end  in  his  relegating  it  to  his  bygone  histor}^  Ribot  has 
well  described  the  process  of  recollection  and  localisation  of  events 
in  time.  He  indicates  how  the  mind,  as  it  were,  travels  back  along 
certain  definite  lines,  not  recalling  the  myriad  of  events  intervening, 
but  leaping  from  certain  prominent  stations,  or,  as  he  calls  them, 
*'  reference-points,"  until  it  arrives  at  the  desired  ej^och,  and  thus,  as  it 
were,  laying  down  a  measuring-rod  which  defines  the  two  points  in 
time.  "Without  this  abridged  process  and  the  disappearance  of  a 
prodigious  number  of  terms,  localisation  in  time  would  be  very  long 


SENILE   AMNESIA.  423 

and  tedious,  and  restricted  to  very  narrow  limits  "  ;  and  again,  ''  by 
repetition  the  localisation  becomes  immediate,  instantaneous,  auto- 
matic "  (pp.  52,  53).  This  does  not  accurately  describe  the  process  for 
all,  inasmuch  as  the  process  varies  much  with  different  individuals. 
Thus,  if  we  take  into  account  those  who  "  visualise  "  (in  the  sense  in 
which  this  term  is  used  by  Galton),  we  find  that  the  mind  often  recurs 
immediately  to  the  event  in  qu.estion  without  apparent  reference-points, 
and  that  the  greater  or  less  vividness  or  faintness  of  the  image  visualised 
tends  to  localise  the  event  in  time  for  such  subjects  ;  or  that  the  mind 
travels  forwards  from  a  similar  reference-point  to  the  present,  so  re- 
versing the  process  described  by  Ribot,  This  condition  of  mental, 
historical  perspective  steadily  declines  in  senile  dementia ;  so  that 
localisation  in  time  becomes  to  many  quite  impossible  ;  present  events 
fail  to  impress  the  organisation  with  their  wonted  vigour,  and  bygone 
experiences  rise  into  undue  prominence,  rivalling  in  their  more  vivid 
reproduction  the  more  recent  occurrences,  and  become,  as  it  were,  pro- 
jected into  the  present.  This  is  what  we  might  anticipate,  as  greater 
resistance  is  ofi'ered  to  the  molecular  currents  of  the  highest  nervous 
mechanism,  the  tide  of  nervoiTS  discharges  must  recede  to  the  more 
deeply-organised  structures.  That  the  latest  acquisitions  and  powers 
suffer  earliest  is  also  exemplified  in  the  failure  of  memory  for  foreign 
languages,  for  late  intellectual  operations  of  abstruse  nature,  and,  in 
fact,  for  all  recent  additions  to  the  individual's  knowledge  ;  the  more 
specialised  knowledge  always  fades  soonest.  So  proper-names  are  for- 
gotten, a  father  may  fail  to  recall  his  children  by  name,  although  he 
recognises  each  individually  ;  or  a  patient,  daily  attended  by  nurse  or 
doctor  for  years,  may  be  unable  to  recall  the  name  of  either.  Sub- 
stantives are  liable  to  be  forgotten ;  as  indicated  by  the  hesitating 
speech,  and  usually  a  dead  stop  at  a  noun.  Dr.  Clouston  truthfully 
portrays  the  typical  senile  speech  as  "  a  mixture  of  a^^hasic,  amnesic, 
and  paretic  symptoms."  *  The  decay  of  the  intellectual  is  followed  by 
failure  of  the  sentient  element  of  mind ;  emotion  and  feeling  become 
slowly  impaired,  but  at  a  much  later  date.  Still,  the  patient  may 
pursue  his  usual  course  of  life,  and  all  deeply-rooted  sympathies, 
weaknesses,  and  prejudices  may  prevail  in  full  force  :  the  customary 
habits  of  a  long  life  maintain  their  ascendancy ;  and  though  special 
aptitudes  fail,  the  ifiiore  general  are  still  retained.  Eventually,  with 
their  decline  the  subject  is  reduced  to  a  mere  vegetative  state  of  ex- 
istence. The  whole  process  forcibly  illustrates  the  law  of  dissolution, 
whereby  the  most-specialised,  most-complex,  and  least-organised  ner- 
vous arrangements  suffer  first,  and  the  more-general,  least-complex, 
and  more-organised  and  stable  nervous-arrangements  are  the  last  to 

*  Op.  cit.,  p.  568. 


424  THE    INSANITY   OF   THE   SENILE    EPOCH. 

succumb;  in  otlaer  -words,  tlie  dissolution  takes  the  course  from  the 
least  to  the  most  stable  arrangements. 

M.  H.,  aged  seventy-six;  widowed.  Has  had  twelve  children,  of  whom  five  are 
living.  A  shrunken,  withered-up  old  woman,  4  feet  10  inches  in  height,  and 
weighing  only  99  pounds.  Skin  of  face  extremely  wrinkled;  slight  arcus  round 
botli  cornea3 ;  the  hair  of  head  scanty  and  white.  She  had  a  demented  aspect, 
■which,  on  excitement,  gave  way  to  a  mischievous,  or  even  malign  expression.  She 
was  well-nigh  edentulous.  Phj-sical  examination  revealed  no  ahnormal  condition 
beyond  very  enfeebled  action  of  the  heart,  and  a  small  weak  pulse.  One  of  patient's 
daughters  was  insane,  her  antecedents'  history  is  free  from  insanitj'  (mother  dying 
at  age  of  ninety-nine),  epilepsy,  apoplexy,  or  phthisis — no  history  of  intemper- 
ance. 

It  was  stated  that  she  was  quite  rational  until  she  was  taken  a  month  ago  to  a 
special  service  of  the  Salvation  Army;  she  was  persuaded  to  preach  and  to  sing 
there,  and  had  never  been  well  since.  She  returned  excited,  irrational,  and  quite 
incapable  of  taking  care  of  herself.  She  talked  almost  exclusively  about  the 
Salvation  Army,  being  full  of  delusional  notions  respecting  their  doings.  Just 
prior  to  admission  her  excitement  became  intense,  she  possessed  herself  of  a  razor, 
and  her  neighbours  believed  she  meditated  suicide;  she  also  applied  a  lighted  stick 
to  the  back  of  her  neck,  and  tried  to  swallow  some  lighted  chips.  Upon  admission 
she  was  noisy,  excited,  clapjiiug  her  hands,  singing  and  talking  incessantl3^  The 
excitement  abated  after  a  few  questions  had  been  put,  and  she  replied  with  fair 
amount  of  coherence.  Her  thoughts  appeared  wholly  occupied  by  religious 
subjects,  and  she  especially  alluded  to  her  attendance  at  Salvation  Army  gatherings. 
Declared  she  had  seen  both  heaven  and  hell — the  latter  "all  fire  and  l^rimstone." 
During  examination  she  heard  voices  from  above,  voices  which  spoke  to  her  of 
heaven,  talked  in  a  hurried,  excited,  and  joyous  strain,  and  mistook  the  identity  of 
those  around  her.  She  says  she  was  told  by  the  Salvation  Army  that  the  pain  she 
felt  at  the  back  of  the  neck  would  be  relieved  by  placing  burning  wood  there  and 
on  her  bosom,  this  she  did,  and  also  swallowed  turpentine  for  a  similar  purpose. 
The  poor  woman,  in  fact,  was  found  by  her  neighbours  experimenting  thus :  her 
door  barred  against  them  by  a  chest  of  drawers,  and  she  herself,  excited,  with  a 
flaring  stick  in  one  hand,  and  a  razor  in  the  other.  Five  days  after  admission,  it  is 
noted,  "always  elated,  talks  much,  pi'ays  much,  declares  she  has  been  here  since 
August,  and  it  is  now  March  (really  January).  This  building  is  the  Salvation 
Army  Barracks  at  ISTewcastle-upon-Tyne."  Again,  a  few  days  later,  "she  is 
extremely  excited,  gesticulating,  tossing  her  arms  about  from  side  to  side,  beUeves 
she  is  captain  of  the  Salvation  Army,  the  asylum  is  their  barracks,  and  she  is  leading 
them  on.  A  few  days  ago  she  refused  her  dinner  because  it  was  poisoned. "  Later 
on,  her  nights  became  greatly  disturbed  by  excitement  and  nois}-  garrulousness ; 
obtahied  sleep  only  when  chloral  was  administered.  Three  weeks  after  admission 
she  was  still  noisy  and  excited,  swore  and  quarrelled,  threatened  the  patients, 
abused  the  nurses,  asserted  she  had  been  here  twentj'^-eight  weeks,  and  had  had 
not  a  bit  of  food;  last  night  thej'  brouglit  her  "what  they  called  tea,  but  she  had 
to  cut  open  her  throat  to  take  the  stutf  out."  -^  gr.  hyoscyamine  ordered  each 
morning.  The  hyoscyamine  at  first  gave  considerable  relief  during  the  day,  and, 
later  on,  her  nights  were  also  less  disturbed  by  excitement ;  but,  her  excitement 
re-appeared,  and  the  hyoscyamine  was  increased  to  i  gr.  The  excitement  was 
characterised  by  coarse,  profane  language;  her  conduct  was  revolting;  her  aspect 
repulsive;  and  speech  and  act  became  tinctured  by  much  obscenitj'.     She  had 


ILLUSTRATIONS    OF   SENILE    INSANITY.  425 

a  very  simian  aspect,  grinned,  grimaced  profusely,  distorting  her  features,  gesticu- 
lating wildl}',  siui^'ing  aloud,  or  laughing  in  a  convulsive  cackling  manner. 

About  four  months  after  admission  the  hyoscyamine  was  replaced  by  a  mixture 
containing  a  drachm  of  the  tincture  of  Indian  hemp,  and  25  grains  of  the  double 
bromide  of  sodium  and  ammonium  for  each  dose  daily.  No  relief  was  afforded, 
however,  and  the  hemp  was  discontinued  after  two  months'  trial. 

This  patient  still  remains  at  the  asj-lum,  now  twelve  months  since  admission. 
Her  physical  health  is  in  a  very  precarious  state ;  she  is  excessively  emaciated, 
and  every  effort  has  to  be  made  to  maintain  her  bodily  heat,  as  she  is  so  incessantly 
restless  and  disorderly  ;  she  is  very  feeble  on  her  limbs ;  her  habits  are  still 
repulsive  and  dirty  ;  her  language  profane,  obscene,  and  irrational.  Still  she  takes 
her  food  well  and  sleeps  better,  and  upon  the  whole  is  less  excited.  The  case  is  a 
typical  one  of  mania  occurring  in  the  course  of  senile  atrophy  ;  the  mental  exalta- 
tion is  a  notable  feature  ;  the  excitement  loud,  boisterous,  unruly,  and  of  long  con- 
tinuance night  and  day  for  weeks  together.  It  also  affords  an  instructive  example 
of  the  effects  of  misguided  religious  services  upon  an  unstable  mental  organisation 
such  as  our  patient's.  The  violent  attempts  prompted  by  her  delusions  illustrate 
also  how  the  exaltation  of  these  senile  dements  may  often  lead  to  suicidal  actions. 
Another  phase  of  her  insanity  was  the  extreme  obscenity  of  her  speech  and  conduct, 
also  a  frequent  accompaniment  in  such  cases. 

The  following  also  may  be  quoted  as  illustrative  of  the  vivid  hallu- 
cinations and  terror  seen  in  these  cases  of  senile  melancholia  during 
the  progress  of  atrophy,  the  dangerous  impulsiveness  to  which  they  are 
liable,  and  the  great  trouble  they  giv^  in  our  asylums. 

M.  M.,  aged  eighty- five.  A  widow  with  two  children  ;  of  Roman  Catholic  per- 
suasion. Was  admitted  October  13th,  18S6,  under  the  following  certificate — 
' '  Chatters  about  dead  people  whom  she  believes  to  be  still  living  in  an  empty 
house  close  by ;  and  one  of  whom  she  talks  of  marrying  to-day.  Believes  herself 
to  be  possessed  of  property.  Rambles  about  in  search  of  imaginary  objects.  At 
one  moment  greatly  distressed  and  crying,  the  next  violent  in  speech  and  conduct. 
Has  to  be  constantly  watched  to  prevent  her  damaging  windows  and  rambling 
from  home.  Threatens  to  kill  her  children  and  burn  her  house  down  ;  attempts  to 
strike  her  grandchildren  with  a  poker."  She  was  said  to  have  been  a  very  steady 
woman  with  no  insane  or  epileptic  inheritance ;  one  daughter  had  died  of  hjemop- 
tysis,  another  of  phthisis.  It  is  affirmed  that  imtil  five  weeks  ago  she  showed 
no  mental  derangement.  She  then  became  excitable,  disorder^,  tossed  food  down 
into  the  cellar  for  others  to  feed  upon ;  soon  became  quite  intractable,  and  several 
times  rushed  upon  her  daughter  with  a  knife.  Has  been  most  destructive  of 
clothing.  "She  has  a  large  dolicho-cephalic  head,  a  very  long  face,  which  is  ex- 
tremely wrinkled  and  pallid,  and  a  fatuous  expression.  The  hair  is  thin  and 
white,  jaws  massive  and  prominent,  few  teeth  remain.  She  is  much  emaciated. 
The  superficial  arteries  show  no  very  decided  cording;  heart's  action  feeble.  There 
is  slight  pulmonary  emphysema.     Examination  of  the  organs  negative. " 

Oct.  2lst,  1SS6. — Restless  and  terrified  last  night ;  kept  looking  at,  and  pointing 
to,  the  windows,  and  declaring  that  "Mahony  was  coming  to  kill  her." 

Od.  25th. — Very  restless  ;  incessantly  trying  to  get  out  of  the  ward  ;  asserts  that 
she  is  "going  home  to-daj'."  To  have  a  mixture  of  tinctura  hyoscyami  with  the 
double  bromides  of  sodium  and  ammonium  twice  daily. 


426  PREMATURE   SENILITY. 

Oct.  30th. — Somewhat  less  restless  ;  seldom  will  stay  in  the  day-rooms  ;  prefers 
being  in  the  corridors  with  the  object  of  getting  through  the  doors.  Says  her 
■"Cousin  is  drinking  up  there;"  she  "is  waiting  for  him;  the  old  rattle-one  is 
coming  after  her  all  the  while."     Cannot  tell  where  she  is.     Sleeps  fairly  well. 

Nov.  St/i. — Required  feeding  by  the  funnel;  is  deluded,  unquiet,  and  speaks 
angrily  against  those  who  feed  her.     Talks  much  in  unintelligible  Irish  brogue. 

Dec.  23rd. — Asserts  that  "  they  are  going  to  kill  her  ;  there  are  some  knives  with 
them  there ;  there  they  are  " — pointing  to  the  ceiling.  Is  very  agitated  and  restless ; 
<loes  not  sleep  well,  and  grows  weaker. 

Feb.  2nd,  18S7.— Often  excited  and  noisy;  on  the  .30th  ult.  refused  her  dinner 
and  remarked — "  I  wont  take  a  bit ;  how  do  I  know  what  poison  I  get?  "  At  times 
fights  with  those  who  approach  her,  evidently  in  terror  lest  they  should  harm  her. 
Is  very  feeble  and  thin  ;  often  requires  a  small  dose  of  paraldehj-d  at  night  to 
secure  sleep. 

April  "ith. — Frequently  distressed  and  weeps,  and  is  often  excited  and  restless, 
searching  for  her  "mother;"  goes  up  to  the  patients,  peers  into  their  faces 
inquisitively,  and  slowly  satisfies  herself  that  thej'  are  not  her  mother.  Is  very 
i'eeble  and  very  thin. 

Jifay  4th. — Declares  that  her  mother  is  upstairs— pointing  to  the  ceiling  ;  often 
talks  to  her  own  reflection  in  the  mirror;  habits  clean;  takes  food  well.  Bromides 
and  henbane  stopped. 

Premature  Senility.^A  careful  compai-ative  .survey  of  the  fore- 
going histories,  with  the  case  of  ff.  0.  detailed  at  p.  210,  will  at  once 
convince  us  that  we  are  dealing  in  both  instances  with  two  obviously- 
distinct  affections  of  the  nervous  system.  In  the  senile  form  we  find 
the  results  of  a  general  decline  in  the  vital  activities ;  the  functions  of 
nutrition,  circulation,  and  the  respiratory  activities  diminished.  So 
also  the  blood-stream  is  impaired  in  quality,  diminished  in  quantity, 
sluggish  in  its  flow ;  and  when  we  turn  to  the  verdict  of  morbid 
anatomy,  the  blood-channels  exhibit  diseased  tunics,  narrowing  of 
their  lumen,  tortuosity  with  attendant  imj^airment  of  their  resilience 
accompanying  atheroma, — the  tissue-elements  universally,  and  the 
brain-cells  in  particular,  presenting  fatty-change  in  their  constituents, 
all  indications  of  a  senile  retrogressive  process. 

The  latter  form  (chronic  cerebral  atrophy)  likewise  presents  a  notable 
vascular  change,  but  of  a  very  different  nature — a  compensatory  hyper- 
trophy of  the  muscular  tunic  of  the  small  vessels,  especially  emphasised 
in  the  cerebral  arterioles,  and  very  frequently  associated  with  advanced 
atheroma  of  the  large  basal  blood-vessels.  This  hypertrophic  condition 
is  also  found  in  varying  degrees  in  the  kidneys,  being  identical 
with  the  changes  described  in  the  arterial  system  by  Dr.  George 
Johnson,  as  those  of  chronic  Bright's  disease,  especially  of  that  form 
associated  with  the  contracted  kidney.  The  imperfect  renal  function 
is  manifested  in  nearly  all  these  instances  of  chronic  brain  atrophy, 
as  may  be  illustrated  in  the  following  table,  containing  the  results  of 
examination  of  the  urine  in  seven  typical  instances,  followed  for  the 


ELIMINATION   OF    UREA    IN   CHRONIC    BRAIN   ATROPHY. 


427 


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PREMATURE    SENILITY. 


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CHRONIC   CEREBRAL   ATROPHY    AND    BRIGUt's    DISEASE.  429 

contrast  by  a  case  of  general  paralysis  (./.  //.),  and  one  of  acute 
delirious  mania  {T.  R.).  The  urea  was  estimated  in  these  cases  by 
means  of  Gerrard's  ureometer,  and  the  amount  in  health  normal  for 
each  individual  was  obtained  by  Parkes'  empirical  formula,  having 
regard  to  the  sex,  body-weight,  quiescent,  or  active  condition  of  the 
patient.  When  these  conditions,  together  with  those  dependent  upon 
diet  are  allowed  for,  we  still  find  a  considerable  deficit  in  the  amount 
of  urea  daily  eliminated.  Two  cases  out  of  the  seven  revealed 
albumen,  and  only  to  a  slight  degree. 

The  history  of  such  patients  points  very  decisively  towards  the 
morbid  change  being  expressive  of  a  general  constitutional  derangement, 
which  we  must  identify  with  chronic  Bright's  disease,  and  which 
expends  its  force  with  varying  degrees  of  intensity — 

1.  Upon  the  minute  arterioles  of  the  kidney,  productive  of  the  small 
contracted  organ  met  with— 

2.  Upon  the  minute  cerebral  arterioles  issuing  in  this  chronic  atrophy 
of  the  brain— 

3.  Or  is  chiefly  emphasised  in  the  vascular  apparatus  of  the  spinal 
cord. 

In  all  such  cases  alike  we  have  similarly-disturbed  functional  prodro- 
mata  with  associated  neuroses;  in  all  the  high-tension  pulse  is  a 
characteristic  indication;  in  all  a  similar  effect  is  reproduced  upon  the 
heart  and  large  blood-vessels. 

If  we  contrast  the  senile  pulse  where  atheromatous  degeneration 
prevails  with  that  of  a  typical  instance  of  chronic  brain  atrophy,  we 
find  the  former  presents  a  tortuous  artery,  unduly  prominent  and 
visibly  mobile  with  each  pulsation,  giving  a  sphygmogram  of  exceed- 
ingly low  tension,  a  vertical  percussion  up-stroke,  an  almost  equally 
sudden  collapse,  and  a  frequent  diminution  of  the  dicrotic  wave  varying 
with  the  endo-cardial  and  aortic  conditions.  There  may  possibly  be  a 
degree  of  aortitis  deformans,  with  loss  of  normal  elasticity,  associated 
with  more  or  less  aortic  regurgitation;  secondary  undulations  during 
diastole  are  usually  absent. 

In  these  cases  of  cerebral  Bright's  disease,  however,  the  pulse  is 
small,  very  hard  and  incompressible,  in  fact,  indicative  of  a  high  arterial 
tension,  modified  more  or  less  by  a  hypertrophied  left  ventricle;  there 
are  also  a  well-marked  percussion-impulse  A'arying  with  the  degrees  of 
hypertrophy,  a  well-sustained  tidal  and  good  dicrotic  waves,  often 
succeeded  by  a  slight  secondary  undulation  during  the  diastolic  pause 
(arterial  elasticity).  In  the  case  of  extensive  atheromatous  disease  a 
tracing-pressure  of  from  30  to  60  grammes  suffices,  and  the  occlusion- 
pressure  is  very  low;  in  the  pulse  of  the  subject  of  chronic  brain  atrophy 
the  hardness  is  so  marked  that  we  have  often  to  employ  a  pressure  of 


430  PREMATURE   SENILITY. 

180  grammes,  and  -with  a  large  liypertrophied  heart  the  pressure  often 
has  to  be  still  further  increased. 

The  obstruction  in  all  these  cases  is  due  to  the  hypertrophy  of  the 
tunica  vucscuhiria.  As  was  indicated  years  since  Ijy  Dr.  Broadbent,* 
the  peculiar  character  of  the  spliygmogram  is  immediately  altered  by 
the  exhibition  of  aniyl,  and  also  by  the  onset  of  jjyrexia.  With  the 
atheromatous  condition,  however,  the  exhilntion  of  amyl,  of  alcohol, 
and  especially  of  alcohol  subsequent  to  chloral,  produces  such  paralysis 
of  the  muscular  tunic  as  often  to  result  in  a  dangerous  vaso-motor 
relaxation — a  condition  not  seen  in  chronic  brain  atrophy  except  with 
the  association  of  extensive  atheroma. 

As  in  the  early  stage  of  Bright's  disease  the  chief  symptoms  are 
those  referrible  to  disordered  digestive  and  assimilative  functions — 
pyrosis,  eructations,  gastralgia,  nausea,  loathing  of  food,  or  a  capricious 
appetite  may  long  prevail  and  constitute  the  premonitory  note  of 
alarm.  Then  follow  evidences  of  depraved  blood ;  of  the  hydrsemia 
associated  with  adventitious  irritating  substances  which  fail  to  be 
eliminated  ;  the  red-corpuscles  decrease  in  number,  and  the  circulatory 
energy  becomes  impaired.  Yet  it  is  in  the  early  prominence  of  nervous 
symptoms  that  we  see  indicated  the  tendency  to  issue  in  brain  disease. 
All  cases  of  Bright's  disease  exhibit  more  or  less  of  these  nervous 
derangements,  but  such  symptoms  are  peculiarly  emphasised  in  the 
cases  with  which  we  are  now  concerned.  Headache  (often  hemicrania), 
giddiness,  vertiginous  seizures,  syncopal  attacks,  severe  palpitation, 
disordered  sensation  (special  and  general)  are  peculiarly  prominent. 
Some  subjects  are  victims  to  severe  forms  of  facial  neuralgia,  others 
complain  of  great  mental  torpor  with  somnolence  or  even  stupoi*.  A 
deranged  state  of  the  blood,  as  regards  its  quality  and  its  supply  to 
the  central  nervous  system,  explains  to  a  large  extent  these  symptoms 
of  disordered  innervation. 

Just  as  with  the  renal  implication  of  chronic  Bright's  disease,  the 
intensity  of  constitutional  and  local  indications  may  bear  no  constant 
relationship  to  each  other — so  in  these  cases  the  degree  to  which  the 
nervous-centres  are  involved  will  greatly  vary  for  each  individual  case, 
the  local  having  no  constant  relationship  to  the  constitutional.  "With 
the  implication  of  the  nervous-centres  we  may  find  associated  every 
degree  of  renal  and  hepatic  degeneration  and  cardiac  hypertrophy  ; 
but  it  is  more  usual  to  find  the  kidneys  in  a  state  of  early  interstitial 
fibrosis  than  very  extensively  affected  ;  we  usually  find  one  organ  in  a 
much  more  advanced  state  of  degeneration  than  the  other. 

The  special  determining  factor  upon  which  depends  this  tendency  to 

*  Discussion  at  the  Royal  Medical  and  Cliirurgical  Society,  Med,  Times  and 
Gaz,  Dec,  1S72. 


ALCOHOL   AS   AN    ETIOLOGICAL   FACTOR.  431 

implication  of  the  cerebrum  in  particular,  in  cases  of  chronic  Ijrain 
atrophy,  would  appear  from  our  statistics  to  be  alcohol;  a  large 
percentage  of  alcoholic  cases  undoubtedly  succumb  to  this  affection. 
The  selective  power  of  the  brain  for  alcohol  has  probably  much  to  do 
with  this  determination  of  morbid  activity  towards  the  cerebral  blood- 
vessels. Eecognising  in  most,  if  not  in  all,  such  cases,  the  injurious 
effect  of  alcohol  upon  the  blood-plasma,  we  cannot  too  strongly  insist 
upon  the  importance  of  defining  the  constitutional  as  apart  from  the 
local  derangement  in  the  earliest  stages  of  this  affection,  and  of  at 
once  treating  such  conditions  with  the  object  of  evading  the  local 
implication. 


PART    III.— PATHOLOGICAL   SECTION. 

General  Contents.— ^Nlorlnd  Condition  of  Cranial  Bones— Investing  Membranes — 
Brain  Substance — Histological  Elements  of  Cortex — Forms  of  Tissue  Dej^radation 
— Pathological  Anatomy  of  General  Paralysis,  of  Epilepsy,  and  of  Chronic 
Alcoholism. 


GENERAL  PATHOLOGY  AND  MORBID  ANATOr/IY. 

Contents. — The  Cranium — Dura  Mater — Pia-Arachnoid — Arachnoid  Htemorrhage — 
Adherent  Pia — Vascular  Apparatus  —  Congestion — Inflammation — Softening — 
Atrophy — Miliary  Sclerosis — Colloid  Degeneration — Granular  Disintegration  of 
Nerve-cells — Pigmentary  or  Fuscous  Degeneration — Developmental  Arrest  of 
Xerve-cells — Vacuolation  of  Cell-i^rotoplasm — Vacuolation  of  Nucleus — Destruc- 
tion of  Intra-cortical  Nerve-fibre  Plexus — Tissue  Degradation  from  Over-strain 
— Tissue  Degradation  from  Active  Morbid  Processes — Tissue  Degradation  from 
Disuse — General  Summary. 

The  CPanium. — The  bones  of  the  skull-cap  present  as  their  more 
frequent  anomalies  of  texture,  one  or  other  of  the  following  con- 
ditions : — (1)  They  may  be  thickened  even  to  an  excessive  degree, 
and    yet  be  light  in  weight  from  the  abundance  of  rarefied  diploe. 

(2)  They    may  be    increased   in   thickness,   and   heavy  from   general 
increase  in   density  throughout,  and  subpei-iosteal  addition  of  bone. 

(3)  They  may  be  extremely  dense,  but  not  thickened  (on  the  contrary, 
they  may  be  thinner),  and  the  surfaces  eburnated  and  polished  in  aspect. 

(4)  They  may  be  reduced  in  thickness  and  density,  even  to  such  a  degree 
as  to  become  semi-diaphanous  over  certain  regions. 

The  first  condition  (due  to  subjacent  irritation)  is  sometimes 
associated  "with  thickened  and  adherent  dura  mater ;  subacute 
inflammatory  states,  probably,  explain  this  association  of  central 
rarefaction  with  superficial  hyperostosis.  The  second  condition  is  far 
more  frequent,  and  sometimes  leads  to  extremely  heavy  skull-caps ;  it 
may  also  be  due  to  prolonged  and  very  chronic  inflammation  of  the 
texture ;  although  in  many  cases  it  is  probably  the  result  of  repeated 
vascular  engorgements,  and  the  excess  of  nutritive  plasma  brought  to 
these  parts  by  conditions  of  violent  cerebral  excitement,  occurring 
through  a  period  of  many  years  in  chronic  mania.  The  thickened 
dense  skull-cap  is  frequent  in  epileptic  subjects,  and  in  the  dementia 


TIIK    CRANIAL    UONES.  43.'i 

of  chronic  insanity.*  The  inner  surface  may  exhibit  protuberant 
bosses,  frequently  coinciding  with  subjacent  atrophy  of  brain-substance; 
whilst  the  grooving  of  the  vitreous  table  is  converted  into  a  deeji 
channelling,  extending  almost  to  the  cancellated  structure,  and 
bridged  over  here  and  there  by  newly-formed  bony  tissue.  The 
hyperostosis  is  genei'ally  disposed  over  the  whole  of  the  vertex,  but 
is  almost  i-nvariably  most  pronounced  in  the  frontal  and  the  occipital 
regions,  and  more  especially  the  former  locality.  "When,  as  we  occasion- 
ally find,  localised  hypertrophy  occurs,  the  frontal  bone  is  by  much  the 
more  frequent  site  of  the  thickening.  We  have  records  of  fifty-four 
cases  of  localised  hyperostosis,  and  in  thirty-one  of  these  the  frontal 
was  the  site  of  this  bony  increase ;  in  seven  cases  the  occipital,  and  in 
six  cases  the  parietal  were  the  regions  involved. 

A  not  infrequent  disposition,  and  one  which  carries  with  it  con- 
siderable interest,  is  the  thickened  state  of  the  left  frontal  associated 
with  that  of  the  right  occij)ital  regions.  The  frequency  of  cranial 
hyperostosis  may  be  gleaned  from  the  fact,  that  it  presents  itself  in 
one-fourth  up  to  one-third  of  all  cases  of  insanity.  Thus  of  1,5C5  fatal 
cases  of  insanity,  the  cranial  bones  were  thickened  in  404  instances 
(or  25 "8  per  cent.);  and  they  were  indurated,  dense,  and  heavy  in  523 
subjects,  or  334  per  cent. 

The  diminution  in  the  thickness  and  density  of  the  cranial  vault  is 
most  usually  seen  in  senile  atrophy ;  the  process  whereby  such  a 
condition  is  induced  being,  in  fact,  similar  to  that  universally  pre- 
vailing at  this  period.  The  facial  boneS,  however,  are  more  subject 
to  this  atrophic  change  than  those  of  the  cranial  Cavity,  and,  in  fact, 
we  may  note  the  coexistence  of  the  former  with  hypertrophic  thick- 
ening, and  induration  of  the  latter  {Rokitanshj).  The  sutural  lines 
are  usually  the  site  of  most  advanced  atrophy,  and  irregular  depressions 
or  pits  alongside  the  sagittal  suture,  indicate  the  absorption  due  to 
exuberant  Pacchionian  bodies  along  this  course.  The  vitreous  table 
is  more  especially  involved  in  these  senile  cases,  and  the  morbid 
process  is  one  of  eccentric  atrophy,  the  compact  being  gradually 
replaced  by  cancellous  tissue.  Osteophytes  in  the  form  of  irregular 
superficial  masses  on  the  inner  surface  of  the  cranium,  osseous  spiculse, 
plates,  and  small  exostoses  are  occasionally  met  with ;  as  also  a  form 
of  eburnated  osteoma  of  concentric  lamellte  with  radiating  canaliculi, 

*  "  Hyperostosis  almost  always  presents  itself  in  both  its  forms,  namely,  that  of 
deposition  externally  upon  tlie  bone,  and  simultaneous  condensation  of  its  tissue 
(sclerosis).  In  a  few  cases  it  goes  on  to  such  an  extent  that  the  skull  is  not  only 
(according  to  ladelod  and  Ilg)  larger  than  natural,  misshapen,  and  uncommonly 
thick  (9  lines  to  H  or  2  inches),  but  it  also  acquires  a  weight  that  is  almost 
incredible."— PailAcyi,  Anat.,  Rokitansky,  vol.  iii. 

28 


434  MORBID   STATES    OF   THE    INVESTING    MEMBRANES. 

and  devoid  of  blood-vessels  (  Virchow,  Cornil,  and  Itanvier).  All  these 
indicate  "  an  extinct  localised  inllammatory  process,  the  products  of 
■which  here  remain  in  an  ossified  form"  (Griesinger).  Our  own* 
observations  tend  (with  certain  qualifications)  to  confirm  the  opinion 
long  since  expressed  by  Dr.  Bucknill,  that  the  increased  thickness  of 
the  cranium  in  insanity  is  not  connected  with  cerebral  atrophy,  his 
statement  being — "  Some  of  the  heaviest  and  thickest  crania  "which 
■we  have  met  with,  have  occurred  in  instances  in  which  there  was 
little  or  no  cerebral  atrophy ;  and  the  condition  of  the  cranium  where 
thei'e  is  imdoubted  atrophy  of  the  brain,  is  not  unfrequeutly  one  of 
abnormal  tenuity."  * 

Exostoses  and  bony  spiculte  are  exceptionally-  rare  in  those  dying 
insane.  Dr.  Bucknill  states  that  such  outgrowths  were  found  by  him 
in  but  three  cases  out  of  400  siibjects.  Our  own  observations  ■would 
tend  to  render  them  of  even  less  frequent  occurrence ;  since  out  of  a 
total  of  2,616  fatal  cases  of  insanity,  exostoses  occurred  in  but  six 
cases,  and  bony  plates  in  the  membranes  in  eight  other  cases. 

Dura  MateP. — This  tough  inelastic  sac  investing  the  brain  has  so 
long  been  considered  and  described  as  of  double  constitution  (that  is, 
of  dura  mater  proper,  and  parietal  layer  of  arachnoid)  that  it  becomes 
important  to  define  our  position  respecting  its  nature  ere  we  describe 
its  anomalies.  Eokitansky  especially  insists  upon  the  distinction — 
"  We  are  compelled  to  adopt  the  distinction  by  the  substantial  differ- 
ence -which  is  exhibited,  at  least  at  jfirst,  by  morbid  processes  in  the 
two  layers.  Inflammation,  for  instance,  attacks  one  of  the  layers 
independently  of  the  other,  and  presents  differences  accordingly  in  its 
course,  in  its  proneness  to  extend  along  the  surface,  and  in  the  pro- 
ducts it  furnishes,  which  manifest  the  analogy  between  that  layer 
and  serous  membrane  in  general."'  t  Despite  the  assertion  of  so 
eminent  an  authority,  the  tendency  of  modern  anatomists  has  been 
towards  the  contrary  opinion.  The  epithelial  layer,  forming  the  inner 
smooth  surface  of  the  dura  mater,  is  now  generally  regarded  as  proper 
to  that  membrane,  and  not,  in  the  true  sense  of  the  word,  a  reflection 
of  arachnoid.  One  fact,  which  tended  to  emphasise  the  divergence  of 
opinion  respecting  this  anatomical  structure,  was  the  frequency  of  the 
formation  of  so-called  arachnoid  cystS  within  the  cavity  embraced 
bet^ween  dura  and  visceral  arachnoid.  A  certain  number  of  patho- 
logists regarded  their  origin  as  haemorrhag"ic,  pure  and  simple ; 
another  class  viewed  them  as  products  of  true  inflammatory  condi- 
tions ;  and  the  latter  naturally  held  that  ^the  inner  surface  of  dura, 
to  which  they  are  often  attached,  is  a  true  serous  surface,  giving  rise 

*  Psychological  Medicine,  Bucknill  and  Tukc,  3rcl  edit. ,  r-  5G6. 
t  "Pathological  Anatomy,"  iSyd.  Soc.  7''rciut\,  vol.  iii.,  p,  323. 


MORBID   STATES   OF   TUE    DUUA    MATER.  435 

to  these  inflammatory  exudates.  With  Axel-Key,  and  Pictzius,  we 
would  describe  a  visceral  arachnoid  only,  so  that  the  structures  and 
spaces  formed  between  the  cranial  bones  and  the  brain  would  bo  from 
without  inwards;  (a.)  dura  mater ;  (b.)  suh-dural  space  {formerly  the 
^^  arachnoid  sac");  (c.)  arachnoid;  (d.)  sub-arachnoid  cavity ;  (e.)  _^;ia 
mater;  (f.)  epicerebral  space. 

It  must  be  remembered  that  this  tough  fibrous  membrane  is  firmly 
attached  to  the  inner  surface  of  the  cranium,  as  its  inner  periosteum  ; 
but,  the  attachment  amounts  to  firm  adhesion  along  the  sutural  lines, 
and  at  the  basal  openings,  foramen  ovale,  foramen  lacerum,  and 
foramen  magnum.  It  is  supplied  with  blood  from  the  various  menin- 
geal branches,  and  a  rich  supply  of  nerves  from  the  fifth,  twelfth,  and 
sympathetic ;  in  inflammatory  conditions  of  the  bone  and  of  this 
membrane,  the  inelastic  nature  of  the  dura  sets  up  very  acute  pain 
from  compression  of  these  nervous  filaments  (Buret). 

Adhesion,  to  a  morbid  degree,  betwixt  this  membrane  and  the  bones 
of  the  cranium  is  of  frequent  occurrence  in  chronic  insanity ;  partial 
adhesions,  indicative  of  bygone  inflammatory  change,  are  found  in 
some  15  per  cent,  of  those  dying  insane,  whilst  universal  strong  adhe- 
sions were  established  in  90  out  of  1,565  fatal  cases  of  insanity  (a  per- 
centage of  5'7).  The  favourite  site,  as  before  stated,  for  partial 
adhesions  is  the  frontal  bone,  either  along  the  course  of  the  coronal 
suture,  or  in  the  hollow  corresponding  to  the  external  prominences  of 
the  frontal  bosses  (10  per  cent.);  the  next  more  frequent  site  is  the 
sagittal  line  and  the  parietal  bone  on  either  side.  In  a  small  propor- 
tion of  cases,  sixteen  only  (1  per  cent.),  the  chronic  inflammatoiy 
change  had  induced  a  noticeable  thickening  of  the  dura ;  and  in  a  still 
smaller  category  was  its  appearance  as  to  colour  modified  from  the 
engorgement  of  its  small  vessels  (in  such  cases,  the  texture  was 
softened  and  infiltrated,  and  the  subjacent  bone  similarly  involved). 
Morbid  adhesion  betwixt  this  membrane  and  the  arachnoid  and  brain 
is  of  very  rare  occurrence ;  we  have  seen  it  in  but  -6  per  cent,  of  our 
cases ;  and  this  we  regard  as  another  indication  of  the  nature  of  the 
epithelial  lining  of  the  dura,  which  seems  to  present  no  morbid 
sympathy  wiflh  the  true  arachnoid  or  to  be  liable  to  adhesive  inflam- 
matoiy states.  Ptokitansky  has  affirmed  the  frequency  of  such  con- 
nections, but  we  fail  to  verify  his  statement ;  at  all  events,  amongst 
the  insane  community.*  The  adhesions  are  often  so  extensive  and 
firm  that  it  is  difficult  to  remove  the  brain  without  injuring  the 
organ ;  hence,  the  skull-cap  with  its  attached  dura  have  to  be  removed 
together.      On   attempting  to   separate    it    from   the  bones   in   these 

*  See  also  on  this  point  Dr.  Bucknill :  Peycholo'jkal  Mcdkine,  Bucknill  and  Take, 
p.  568. 


436  MORDID    STATES    OF    THE    INVESTINO    MEMBRANES. 

extreme  forms,  we  fail  to  do  so,  as  the  membrane  tears  into  shreds, 
or  splits  up  into  layers,  leaving  irregular  white  glistening  membranous 
lamellfe,  strongly  contrasted  with  the  rosy  or  deeper  tinted  bone 
around.  All  this  is,  of  course,  indicative  of  the  results  of  old-standing 
inflammation. 

Bony  plates  within  this  membrane,  as  a  result  of  further  change  in 
the  inflammatory  exudate,  occurred  in  8  cases  out  of  a  total  of  2,616. 
It  is  probable  that  the  exostoses  described  on  the  inner  surface  of  the 
bones  of  the  skull  have  their  origin  often  in  the  membrane  itself,  or  in 
exudate  intervening  betwixt  the  two.  In  one  remarkable  case  the 
whole  of  the  falx  cerebri  was  thus  ossified  into  a  corresponding  sickle- 
shaped  bony  plate,*  such  as  permanently  obtains  in  the  ornitho- 
rhynchus  ;  on  the  other  hand,  a  bony  tentorium  cerebelli,  which  we 
know  is  normal  in  many  mammals,  we  have  never  seen  amongst  the 
insane. 

The  Pia  Arachnoid. — A  milky  cloudiness  of  the  arachnoid  is  seen 
in  most  brains  of  those  dying  at  middle  age,  and  the  opacity  becomes 
more  decided  with  advancing  years,  until,  in  the  aged,  it  is  seen  to  a 
notable  degree,  apart  from  any  actual  cerebral  disease.  It  has  been 
invariably  attributed  by  pathologists  to  frequent  congestive  conditions 
^chronic  hyperaemia)  of  the  membrane,  to  which  (as  Rokitansky  affirms) 
every  one  at  an  advanced  age  must  have  been  occasionally  subject. 
Whatever  be  the  explanation  in  the  comparatively  healthy  brain,  there 
is  no  doubt  that  in  the  extreme  degi'ees  of  this  change,  seen  in  the 
insane,  we  must  infer  a  chronic  inflammatory  agency.  In  senile 
atrophy  of  the  brain  we  see  this  physiological  retrogression  emphasised, 
opacities  and  thickening  of  texture  being  often  marked  features  here, 
apart  from  any  inflammatory  change;  the  outbursts  of  senile  mania 
are,  however,  often  associated  with  a  chronic  meningo-cerebribis,  which 
subsequently  reveals  itself  in  morbid  adhesions  betwixt  the  brain  and 
soft  membranes. 

It  is  peculiarly  frequent  in  those  prone  to  alcoholic  intoxication 
{Rokitanshy,  Griesinger),  and  we  have  seen  it  as  a  constant  change  in 
the  brain  of  the  sane  and  insane  criminal  class — which  class  is,  to  a 
notorious  extent,  addicted  to  intemperance.f  In  the  insane  community 
generally,  we  have  found  arachnoid  opacity  prevails  to  a  notable  degree 

*  "A  similar  structure,  constituting  an  unique  specimen  of  anatomical  variety, 
is  exhiljited  in  the  slvull  of  a  female  l)elonging  to  my  collection  "  [Blumcnhach). 

t  "It  may  be  generally  considered  as  the  result  of  former  chronic  hypenemia  and 
inflammatory  stasis ;  it  accordingly  occurs  together  with  increase  of  the  Pacchionian 
granulations — which  depends  on  analogous  processes — under  all  circumstances 
where  habitual  cerebral  congestion  existed  during  life,  as  in  the  case  of  drunkards, 
who,  indeed,  can  rarely  be  considered  as  mentally  healthy."  Griesinger  on  "Mental 
Diseases,"  Syd.  Soc,  1867,  p.  418. 


MORBID   STATES   OP   TUE    PIA   ARACHNOID.  437 

— in  nearly  50  per  cent.  (772  out  of  1,565  cases) — and,  as  usual,  most 
marked  along  the  sulci  and  the  immediate  vicinity  of  the  blood-vessels. 
It  is  usually  associated  with  considerable  thickening  of  the  pia 
arachnoid  (the  pia  is  abnormally  thickened  in  fully  48  per  cent,  dying 
insane),  partly  from  fibrinous  exudates  which  have  organised,  partly 
from  plastic  lymph,  and  often  from  an  cedematous  swollen  condition  of 
the  conjoined  soft  membranes,  and  the  trabeculae  intervening  betwixt 
them  in  the  sulci,  resulting  in  a  watery,  semi-translucent,  gelatinous 
appearance,  with  here  and  there  scattered  patches,  points,  or  streaks  of 
opacity.  The  outer  surface  of  the  ai'achnoid,  covered  with  a  delicate 
pavement-epithelium,  becomes  at  times  perceptibly  rough  and  granular, 
both  to  the  touch  and  to  naked-eye  examination;  the  condition 
resembling,  histologically,  the  granular  condition  of  the  ependyma,  or 
lining-membrane  of  the  ventricles;  it  is  especially  prone  to  occur  at 
both  sites  in  general  paralysis  of  the  insane. 

The  conditions  above  referred  to  of  opacity  v/ith  thickening  of  the 
pia  arachnoid  may  be  unattended  with  any  excess  of  fluid  in  the  sub- 
arachnoid space;  usually,  however,  in  the  chronic  insane,  great  excess 
prevails,  so  that  the  normal  limpid  cerebro-spinal  fluid  (which  varies 
considerably  between  2  drachms  and  2  ounces)  may  be  very  largely 
augmented  up  to  8  or  10  ounces;  the  soft  membranes  are  buoyed-up 
by  such  accumulation,  and  their  meshes  become  thickened,  glutinous,  and 
water-logged.  The  fluid  is  acid  in  reaction,  whilst  the  normal  cerebro- 
spinal fluid  is  alkaline.  It  must  be  borne  in  mind  that  this  sub- 
arachnoid cavity  is  continuous  with  the  general  ventricular  cavities  of 
the  hemisphere,  with  the  central  canal  of  the  spinal  cord,  and  with  the 
sub-arachnoid  space;  products  of  inflammatory  activity  being  thus 
capable  of  transmission  to  distant  parts  by  the  movements  produced  in 
this  fluid  during  locomotion,  respiration,  and  circulation,  all  of  which 
are  known  to  affect  the  cerebrum. 

In  connection  with  the  arachnoid  there  is  an  important  morbid 
state,  the  frequency  of  which,  in  insanity,  and  especially  certain  chronic 
forms  of  insanity,  makes  it  a  striking  feature  in  our  post-mortem  records; 
the  condition  referred  to  is  that  of  false  membranous  productions, 
enclosing  various  contents  from  straw-coloured  serum  to  thin  bloody 
serum,  or  blood  partly  or  completely  clotted.  These  formations  have 
been  often  referred  to  by  the  inapt  term  of  arachnoid  cysts.  When 
they  occur  as  gelatinous-looking  exudates  or  pseudo-membranous 
structures  upon  the  inner  surface  of  the  dura,  they  have  been  regarded 
as  inflammatory  in  origin,  and  have  been  described  by  Virchow  as 
pachymening'itis  interna,  in  accordance  with  the  view  of  Calmeil, 
Boyle,  and  others.  We  incline  strongly  to  the  view  that  the  inflam- 
matory theory  of  their  origin  cannot  be  supported  by  a  tithe  of  evidence 


438  MORBID    STATES   OF   THE    INVESTING   MEMBRANES. 

from  asylum  experience;  there  can,  we  tliink,  Ijo  little  or  no  doubt 
that,  in  tlic  case  of  those  dying  insane  at  least,  we  must  claim  a 
hSBniOrrhag'ic  OPig"!!!  for  sucli  formations.  Their  frequency  may  be 
judged  of  from  the  fact  that  81  cases  are  recorded  in  1,565  autopsies  of 
the  insane,  and  their  special  frequency  in  that  form  of  insanity  which 
is  associated  with  general  pai'alysis,  is  emphasised  by  the  occurrence  of 
30  instances  in  a  series  of  242  general  paralytics  (a  percentage  of  12). 
The  appeai'ances  presented  by  them  vary  considerably  with  the  stage 
at  which  they  are  found.  In  early  stages  we  may  find  a  sliglit  rusty- 
staining  over  a  more  or  less  localised  patch  of  the  inner  surface  of  the 
dura,  or,  perhaps,  covering  the  whole  area  of  one  of  the  fossje  (and 
especially  the  middle  fossa  at  the  base  of  the  skull);  over  this  rusty- 
stained  groundwork  minute  droplets  of  blood  are  seen,  as  if  besprinkled 
by  a  brush,  or  as  if  the  blood  had  oozed  from  the  surface  by  a  sort  of 
sweating  process.  The  rusty-staining  can  be  scraped  off  as  an  extremely 
delicate  and  structureless  pellicle.  Or,  again,  the  inner  surface  of  the 
dura  may  overspread  a  somewhat  amber-coloured  glutinous-looking 
layer,  which  can  be  readily  stripped  off  and  appears  to  be  a  purely 
fibrinous  formation,  enclosing  more  or  less  arterial  blood.  Such 
structures  form  translucent  pellicles,  which,  when  examined,  look  like 
gutta-percha  tissue  stretched  to  a  delicate  tenuity.  The  extravasation 
is  often  extensive,  flattening  the  convolutions,  and  inducing  consider- 
able atrophy — a  simple  dark  clot  of  blood  moulded  to  the  form  of  the 
arachnoid  cavity  occupied  by  it,  thick  at  its  central  parts,  thinning 
out  towards  its  margin,  and  covered  with  a  delicate  fibrinous  layer 
above  and  below;  or  the  fibrinous  -formation  may  be  thicker,  more 
organised,  and  may  constitute  a  complete  sac  enclosing  the  blood-clot. 
E/okitansky's  classical  description  holds  good  for  the  formations  in  the 
insane. 

"Its  adhesion  with  the  dura  mater,  too,  is  loose  ;  it  partly  sticks  on,  and  partly 
is  connected  with  the  membrane  by  a  few  small  vessels.  Both  walls  of  tlie  sac  arc 
usually  of  a  brown,  rusty  colour,  and  tenacious.  They  may  often  be  separated 
into  several  layers  which  vary  in  thickness,  but  the  inner  of  which  are  more  thin  : 
at  the  margin  of  the  sac  they  coalesce  and  form  one  lamina,  which  soon  becomes 
reduced  to  a  thin,  brown,  rusty-coloured  membrane,  and  spreading  out  further  on 
the  cranial  vault,  reaches  to  the  base,  and  at  length  terminates  in  a  thin,  rusty- 
coloured,  gauze-like  film  .  .  .  within,  the  sac  contains  a  more  or  less  thick 
fluid,  of  a  dark  and  various  colour,  like  chocolate,  or  plum-sauce,  rust,  or  yeast;  in 
course  of  time  the  lympli  is  gradual!}' removed,  the  inner  surface  of  the  sac  becomes 
smooth  and  polished,  and  the  contents  are  changed  into  a  colourless,  thin,  clear, 
serous  fluid."* 

"We  have  never  observed  what  the  same  authority  states  is  of 
occasional  occurrence,  viz.,  the  ossification  or  formation  of  bony  plates 

*  Op.  clL,  p.  330, 


ORIGIN    OF    ARACHNOID    IliEMORRHAGE. 


439 


or  concretions  on  its  outer  wall  next  the  dura.  Some  of  the  more 
cogent  reasons  for  regarding  these  formations  as  non-inflammatory 
are  : — 

1.  The  cyst  is  readily  removable,  slightly  (or  not  at  all)  adherent  to 
the  dura  mater. 

2.  In  the  majority  of  cases  there  is  no  evidence  whatever  of  the 
existence  of  a  pachymeningitis ;  («)  the  dura  is  not  thickened  or 
softened,  or  vascular ;  (&)  no  organic  connection  exists  betwixt  the 
two. 

3.  In  eai'ly  stages  the  characters  are  purely  those  of  a  simple  extra- 
vasation of  blood  into  the  arachnoid  cavity  (subdural  space). 

4.  There  is  the  co-existence  in  this  affection  of  a  recognised  vascular 
disease  and  vasomotor  disturbances  which  render  liDamorrhage 
frequent,  e.g.,  the  othsematoma  or  "  insane  ear." 

In  an  important  communication  my  former  colleague,  Dr.  Robert 
Lawson,  expressed  the  same  views  as  are  here  entertained.'" 

As  regards  their  cause  and  origin  and  general  etiological  relationship 
amongst  the  insane,  it  has  been  pointed  out  by  Sir  J.  Crichton-Browne 
that  the  age  of  their  more  frequent  occurrence  was  between  35  and  45 
years — an  important  feature  as  distinctive  between  it  and  ordinary 
forms  of  cerebral  haemorrhage,  which  occurs  more  frequently  at  a  much 
later  period  of  life.  The  same  authority  in  an  analysis  of  fifty-nine 
cases  of  arachnoid  cyst,  occurring  at  the  West  Hiding  Asylum,  has 
clearly  established  the  vast  preponderance  of  this  accident  in  cases  of 
general  paralysis,  as  seen  in  the  following  table 


FIFTY-XINE    CASES    OF    ARACHNOID    CYST 


General  paralysis  afibrds 
Chronic  disorganisation  of  brain 
Senile  atrophy 
Epilepsy 

Mania  associated  with  chorea 
Mania  with  meningitis 
Insanity  witli  Bright's  disease 
Chronic  mania  with  phthisis 


29 
16 

3 


59 


As  regaixls  sex,  it  is  recognised  as  occurring  more  frequently  in  men, 
from  very  obvious  reasons ;  the  most  important  being  the  greater 
frequency  of  its  congener,  general  paralysis,  in  the  male  than  in  the 
female. 

Our  records  embrace  the  histories  of  73  additional  cases  since  the 
above  were  tabulated  by  Sir  Crichton-Browne,  and  these,  arranged  as 


*  See  footnote,  p.  440. 


440 


MORBID   STATES    OF   THE    IN'VESTINr,    MEMBRANES. 


to  associated  cerebral  states  and  sex,  illustrate  forcibly  the  foregoing 
statements  : — 

SEVENTY-THREE    CASES    OF   ARACHN'OID  CYST. 

General  paralysis    afforded   instances   in   30  Males  and  4  Females. 


Chronic  disorganisation  of  the  brain 

Senile  atrophy 

Epilepsy 

Mania     . 

Melancholia    . 

Idiocy     . 


12 
G 
3 
2 
1 
1 


IS 


Or  summarising  both  series  we  have  132  instances  of  ai'achnoid  cyst; 
63,  or  47'7  per  cent.,  occur  in  general  paralysis;  35,  or  26-5  per  cent., 
in  chronic  disorganisation  of  the  brain;  12,  or  9  per  cent.,  in  senile 
atrophy;  7,  or  5-3  per  cent.,  in  epilepsy  ;  and  15,  or  11 '3  percent.,  in 
several  other  forms  of  mental  ailment. 

The  site  of  haemorrhage  is  almost  exclusively  confined  to  the  vertex 
and  lateral  aspects  of  the  cerebrum ;  we  have  never  seen  it  on  the 
lower  aspect  of  the  tentorium  or  within  the  cerebellar  fossa  of  the 
cranium  ;  it  is  also  of  rare  occurrence  in  the  anterior  and  middle  fossa? 
at  the  base. 

The  left  hemisphere  is  more  frequently  the  site  of  the  haemorrhage 
than  the  right,  as  indicated  in  the  sixty-five  more  recent  cases 
extracted  from  our  records. 


SITE   OF   AKACHNOID    II^MOREHAGE   IN    SIXTY-FIVE   CASES. 

Both  hemispheres  generallj'  covered  above 
Left  hemisphere  ,,  ,,  ,, 

Ivight  hemisphere         ,,  .,  ,, 

Ilight  parieto-occipital  region     . 
Right  frontal  region  .... 

Anterior  fossa  at  base         .... 
Anterior  and  middle  fossce 


2S 
20 
II 

r> 

1 
1 

2 


The  extravasation  most  probably  occurs  from  a  vessel  of  tlio  pia 
mater,  the  vessels  of  which  in  general  paralysis  show  very  special  lesions 

*  Dr.  Lawson's  statement  is  to  the  following  effect :  —  "  Amongst  the  sane, 
amongst  drunkards,  and  in  cases  where  injury  has  induced  pachj-meningitis 
externa,  this  production  of  arachnoid  cysts  by  the  rupture  of  vessels  formed 
in  inflammatory  products  might  readily  occur.  .  .  .  It  is  evident  that  at 
least  the  large  majority  of  cases  of  hsBmatoma  in  the  insane,  originate  in  direct 
rupture  of  vessels  and  extravasation  into  the  arachnoid  sac."  (Brit,  and  For.  Med. 
Chir.  Review,  1876). 


ADHESION    OF    PI  A    TO    CORTEX.  441 

forming  disc  of  tlio  most  constant  cliangos  in  this  affection.  The 
diseased  condition  of  their  tunics,  which  we  shall  allude  to  later  on,  is 
greatly  aggravated  by  the  repeated,  violent,  and  long-continued  out- 
bursts of  excitement  to  which  such  cases  are  subject;  and  the  vessels 
Avhich  have  undergone  most  change  are  decidedly  those  in  the  an- 
terior regions  of  the  brain,  coinciding  with  the  more  frequent  site- 
of  these  arachnoid  haemorrhages.  The  arteries  coursing  within  the 
sulci  are,  of  course,  better  protected  by  the  support  they  receive,  thaa 
the  veins  distributed  over  the  exposed  surface  of  the  gyri ;  at  th® 
summits  of  the  gyri  there  is  evidence  of  inflammatory  activity,  well 
marked  in  the  presence  of  meningeal  adhesions.  The  Avascular  net- 
work supported  by  the  pia  at  these  sites  is  most  affected  by  the  morbid 
changes  taking  place,  and  hence,  the  venules  are  kept  in  a  state  of 
continuous  engorgement  near  the  site  where  they  empty  into  the 
larger  veins  running  to  the  sinuses,  a  condition  further  aggravated 
by  the  active  arterial  flow  of  functional  excitement.  Thus,  in  our 
opinion,  the  occurrence  of  at  least  a  large  proportion  of  these  forma- 
tions is  explained  as  due  to  : — • 

(rt.)  The  initial  diseased  condition  of  the  vascular  tunics. 

(b.)  The  distended  condition  of  the  venous  system  from  atrophyj. 
and  consequent  loss  of  support,  and  obstructive  conditions  due  ta 
inflammatory  change. 

(c.)  The  anatomical  arrangement  of  the  veins,  involving  them  in  the- 
most  pronounced  inflammatory  change. 

We  have  alluded  to  the  evidence  of  congestive  and  chronic  inflam- 
matory conditions  presented  in  the  notable  opacity,  with  thickening  of 
the  soft  membranes,  the  presence  of  efi"vised  lymph,  and,  we  might  add, 
the  somewhat  rare  condition  of  purulent  infiltration  of  the  membranes 
at  the  vertex  in  certain  forms  of  insanity.  To  these  we  must  add, 
as  indubitable  evidence  of  inflammatory  activity  in  the  cortex  and  its- 
investing  membranes  (chronic  meningo-cerebritis),  the  frequency  of 
morbid  adhesions  between  these  structures.  Such  morbid  adhesions 
occur  in  chronic  insanity,  in  chronic  mania,  in  senile  mania,  occasion- 
ally in  alcoholic  insanity,  and  especially  in  the  mental  derangement 
associated  with  traumatism.  It  is,  however,  in  general  paralysis  of 
the  insane  that  this  condition  forms  so  important  a  feature  as  to 
constitute  the  one  distinctive  sign  indicative  of  this  disease  to  the 
}iathologist.  In  a  small  percentage  of  cases  only  is  this  important 
sign  absent  ;  but  in  such  exceiDtional  forms  other  indications  are 
sufiiciently  expressive  of  the  nature  of  the  diseased  process.  We  shall 
describe  in  detail  the  morbid  process  as  it  occurs  when  dealing  with 
the  special  pathology  of  general  paralysis.  For  the  present  Ave  haA-e 
to  deal  Avith  the  general  features  presented  by  such  adhesions  in  this 


442  THE    MOKBID    DRAIN    IX    INSANITY. 

and  othei-  forms  of  mental  disease.  I  find  from  Dr.  Bullen's  statistical 
compilation  from  our  West  Riding  Asylum  llecords,  that  out  of  1,5G5 
fatal  cases  of  insanity,  morbid  adhesions  betwixt  brain-cortex  and  in- 
vesting membranes  had  been  contracted  in  340  instances,  or  21*7  per 
cent,  of  the  whole ;  whereas  in  a  former  study  of  general  paralysis,  some 
years  back,  we  found  that  in  241  cases  of  this  disease  which  had  proved 
fatal,  ISG  (or  over  77'1  jier  cent.)  presented  well-marked  adhesions, 
the  remaining  fifty-five  (or  22-8  per  cent.)  being  described  as  free  from, 
such  implication.  We  must,  however,  be  prepared  to  meet  with 
cases  where  it  may  be  dubious  how  far  we  should  regard  the 
connection  as  amounting  to  a  morbid  adhesion ;  but  in  our  statistical 
results  above  recorded,  we  include  only  such  instances  where  the 
removal  of  the  membranes  necessitates  a  teariivj-away  of  the  superficial 
cortex.  Undoubtedly,  many  other  cases  of  morbid  firmness  of  union 
present  themselves,  which,  therefore,  escape  from  this  category ;  and 
this  was  the  case  in  many  of  the  22-8  per  cent,  in  which  genuine 
adhesions  were  excluded.  The  brain  of  the  alcoholic  presents  instances 
of  this  morbid  firmness  of  union;  and,  histologically,  this  is  attested 
to  in  the  presence  of  the  same  morbid  elements  which  are  found  so 
profusely  scattered  thi'ough  the  cortex  in  genuine  cases  of  adhesion  ; 
but  we  do  not  find  in  the  alcoholic's  brain,  as  a  rule,  anything  more 
than  this  undue  firmness  of  union. 

On  attempting  to  strip  ofi:"  a  portion  of  adherent  membrane,  there 
are  seen  by  the  naked-eye  numerous  tough  fibrous  prolongations,  which 
look  like  enlarged  blood-vessels,  connecting  the  under-surface  of  the 
pia  with  the  cortex  of  the  brain.  W^hen  forcibly  removed,  the  upper 
layers  peel  away  to  varying  depths  upon  the  pia,  leaving  an  ei'oded 
surface  which  presents  a  highly  characteristic  aspect.  The  surface 
looks  gnawed  or  worm-eaten  along  the  length  of  the  gyri  with  irregular 
sinuous  margins,  so  that  it  somewhat  resembles  the  aspect  pre- 
sented by  a  succulent  leaf  which  has  been  attacked  by  a  caterpillar. 
The  base  of  the  eroded  (or  rather,  torn)  surface  is  distinctly  punctated 
by  large  open  orifices  from  which  coarse  vessels  have  been  withdrawn. 
Adhesions  of  some  age  exhibit  a  coarse  dense  fibrillar  connection 
betwixt  pia  and  cortex ;  the  normally  delicate  retiform  aspect  of  the 
neuroglia  is  lost  in  the  coarse  fibrillation  which  has  ensued.  In  earlier 
stages  the  appearance  is  suggestive  of  inflammatory  implication,  in  the 
distinctly-pinkish  appearance  of  the  cortex,  sometimes  difi'used,  some- 
times limited  to  the  areas  of  recent  adhesions  ;  the  pia  is  thickened  and 
tumid,  the  seat  of  nuclear  proliferation,  its  vessels  deeply  engorged 
and  the  superjacent  arachnoid  also  thickened,  opaque,  and  cedematous. 
The  distended  vessels  are  coarse  and  tortuous,  their  sheaths  thickened 
hy  multiplication  of  their  cells  and  the  traversing  of  their  structure  by 


MORBID    VASCULARITY    OF    THE    CORTEX.  443 

wandering  leucocytes.  The  microsco[)e  reveals  infiltration  of  the  cortex 
by  large  numbers  of  peculiar  spider-like  cells — oval,  Hask-shaped  or 
globose — but  all  throwing  ofl"  numerous  delicate  fibrillar  processes  which 
entwine  upon  the  vascular  walls  and  meander  amongst  the  nerve- 
elements  of  the  cortex.  Such  spider-like  cells  are  found  in  all  recent 
adhesions  in  the  upper  layex'S  of  the  cortex,  immediately  beneath  the 
adherent  pia,  forming  a  direct  connection  with  its  under  surface 
and  the  vessels  passing  from  it  into  the  substance  of  the  Itrain. 
Around  the  vralls  of  the  blood-vessels  these  elements  tend  especially  to 
crowd,  and  their  ramifying  extensions  will,  probably,  by  subsequent 
contraction,  seriously  interfere  with  the  permeability  of  these  channels 
of  nutrierd  supply.  The  prominent  role  assumed  by  these  organisms  in 
general  paralysis  of  the  insane,  the  frequency  with  which  they  are 
seen,  and  their  very  striking  features,  induced  certain  obseiwers  to 
regard  them  as  pathognomonic  of  this  disease.  We  had,  however, 
some  years  previously  indicated  and  sketched  their  appearance  in 
senile  atrophy  of  the  brain  {PI.  :KN.,fig.  1),  and  had  recognised  their 
existence  in  other  morbid  conditions;*  in  fact,  they  represent  a 
hypertrophied  state  of  what  in  our  section  of  the  normal  histology 
of  the  cortex  we  have  described  as  its  "lymph-connective"  system. 

The  reason  why  these  morbid  conditions  are  not  more  frequently 
seen  in  senile  atrophy  and  other  pathological  states  of  the  brain  is 
that  the  stage  in  which  they  are  formed  is  an  early  stage  of  the  disease, 
a  stage  which  in  most  fatal  cases  has  long  since  passed  by;  the  organisms 
have  succumbed  to  a  fatty  liquefaction  and  so  been  removed  from  observa- 
tion. General  paralysis,  however,  is  a  comparatively  rapid  process  of 
dissolution,  and  intercurrent  affections  often  prove  fatal,  and  afibrd  us 
illustrations  of  its  morbid  anatomy  in  early  stages  ;  hence  these  morbid 
appearances  are  frequently  met  with,  yet  not  constantly,  for,  at  an 
advanced  stage  of  this  affection  also,  the  morbid  cells  degenerate  and 
disappear,  leaving  their  fibrous  meshworks  as  their  sole  representative. 
In  chronic  alcoholism,  again,  such  products  of  morbid  activity  pi-esent 
themselves,  frequently  in  great  abundance,  but  never,  in  our  experience, 
to  the  extreme  degrees  met  with  in  certain  cases  of  senile  atrophy  and 
general  paralysis.  In  fact,  it  is  our  opinion,  based  upon  a  large  number 
of  observations,  that  where  a  specially  irritative  process  is  engendered 
in  the  cortex,  and  more  especially  where  a  large  accumulation  of 
degenerative  material  has  to  be  carried  off  from  this  region,  or  where 
eS'ete  material  accumulates  as  the  result  of  some  obstruction  to  the 
normal  transit  of  lymph  from  the  brain,  there  we  are  likely  to  meet 
with  these  vast  developments  of  "  spider-cells,"  as  they  have  been 
termed.  Hence  in  a  chronic  meningO-CerebritiS,  attended  by  much 
*  Proc.  noy.  Soc,  Ko.  182,  1S77. 


444  THE    MORBID    BRAIX    IN    INSANITY. 

effusion  into  the  vascular  sheath,  by  extravasations  into  the  brain- 
substance,  and  by  the  varied  products  of  inflammatory  engorgement  of 
the  part,  this  "  lymph-connective  system  "  of  the  neuroglia  (as  we  have 
ventured  to  term  it)  undergoes  the  functional  hypertrophy  here  alluded 
to,  in  an  extreme  degree. 

Again,  in  the  later  stages  of  senile  degeneration,  the  fatty  atrophy  of 
texture  has  advanced  to  so  extreme  a  degree,  usually  during  a  very 
prolonged  course  of  many  years,  that  the  surface  of  the  cortex  is 
widely  severed  from  the  membranes  overlying  it  by  the  compensatory 
accumulation  of  fluid  ;  any  delicate  adhesions  which  had  been  formed 
in  early  stages  have  been  softened  and  broken  down.  The  membranes 
are  not  thickened  to  the  same  extent  as  in  general  paralysis,  where 
they  often  form  a  dense,  thick,  felt-like  structure  which  fully  occupies 
the  space  formed  by  the  recession  of  the  atrophic  brain.  The  physical 
conditions,  therefore,  as  well  as  the  more  rapid  course  of  the  one 
compared  with  the  other,  have  probably  much  to  do  with  the  presence 
or  absence  of  adherent  membranes.  We  must,  however,  not  omit  the 
fact,  that  the  tearing  of  the  cortex  is,  to  a  certain  extent,  also  due  to 
the  softening  of  the  outer  layers  of  the  cortex  by  the  inflammatory 
process:  but  this  alone  by  no  means  accounts  for  the  appearances, 
since  the  condition  observed  on  removing  the  membranes  in  a  brain 
simply  softened  by  decomposition,  or  from  those  regions  always  exces- 
sively soft,  at  the  basal  aspect  of  the  cerebrum,  in  no  way  reproduces  the 
appearance  of  the  eroded  cortex  in  general  paralysis. 

The  brain-substance,  both  grey  and  white,  in  fatal  cases  of 
insanity  is  found  in  a  very  variable  condition  of  vascularity  dependent 
frequently  upon  wholly-extrinsic  agencies  and  accidental  states,  which 
are  completely  foreign  to  the  cerebral  disturbance  existing  during  life. 
We  must  remember  the  peculiarities  of  the  vascular  mechanism  we  are 
dealing  with,  which  explain  to  a  great  extent  the  variations  noticed. 
The  pia  mater  is  a  Avondrously  vascular  meshwork,  capable  of  an 
enormous  degree  of  distension  and  venous  engorgement,  as  we  some- 
times see  to  an  astonishing  extent  in  obstructions  to  the  return  of 
venous  blood  to  the  heart,  in  cases  of  intra-thoracic  pressure.  It  serves 
the  purpose  of  bringing  into  immediate  contact  with  the  surface  of  the 
brain  a  very  large  amount  of  venous  blood ;  the  carriers  of  which  are 
so  disposed  as  to  offer  a  direct  mechanical  disadvantage  to  the  return 
of  venous  blood  from  the  cranial  cavity — the  current  of  blood  in  the 
large  cerebral  veins  being  opposed  to  that  of  the  current  in  the  sinuses 
by  their  oblique  direction  and  opening  into  the  sinuses  from  behind 
forwards.  Thus,  whilst  in  the  veins  of  the  lower  extremities,  special 
facilities  (such  as  their  valves)  are  introduced  to  favour  the  circulation 
in  its  return,  the  intracranial  veins  have  a  direct  obstruction  offered 


MORBID    VASCULARITY    OF    THE    CORTKX.  445 

to  the  too  speedy  flow  towards  the  heart ;  an  obstruction  which  even 
leads  to  a  hypertrophic  state  of  the  tissues  in  this  immediate  neigh- 
bourhood.* The  venous  blood  in  this  vascular  membrane  and  system 
of  sinuses  serves  the  purpose  of  keeping  up  a  sustained  backward 
pressure  upon  the  cortical  venules,  and  thus  effectually  provides  for 
the  continued  patency  of  the  minute  vessels  of  the  cortex.  It  is  only 
exceptionally  that  this  patency  is  interfered  with  to  a  state  of  complete 
anfemia,  when,  of  course,  unconsciousness  supervenes.  Sleep  is  an 
instance  of  a  rhythmic  interference  with  this  condition ;  and  the 
agency  whereby  the  ansemia  is  produced  is  well  illustrated  in  Mosso's 
experiments  with  the  plethysmograph,  whereby  he  clearly  shows  a  well- 
marked  dilatation  of  the  peripheral  vessels  as  the  immediate  prelude 
to  sleep.  A  similar  condition  of  things  is  found  at  the  other  extremity 
of  the  cerebral  circulation — viz.,  the  basilar  artery.  Here  we  find  the 
two  vertebrals  taken  together  about  double  the  capacity  of  the  recipient 
basilar  artery ;  and  as  the  result  of  this  a  sustained  pressure  of  no 
inconsiderable  degree  is  kept  up  in  the  minute  nutrient  arteries  passing 
direct  from  it  into  the  substance  of  the  pons.  Hence  these  vitally- 
important  centres  are  kept  continuously  supplied  with  blood,  a  supply 
which  will  only  be  augmented  as  contraction  in  the  distal  cerebral 
branches  produces  ansemia  in  those  parts.  If  we  keep  this  mechanism 
of  the  venous  system  of  the  cortex  in  view,  we  at  once  see  how 
variable  will  be  the  vascular  appearances  of  the  brain  according  to  the 
mode  of  death ;  the  presence  of  obstruction  in  the  heart  and  lungs  to 
the  venous  circulation,  and  especially  obstruction  in  the  cranial 
sinuses,  such  as  frequently  occurs  in  cases  of  insanity.  So  likewise 
the  mode  of  opening  the  body  for  2^ost-7)iortem  examination  greatly 
modifies  the  appearance  of  the  cortex  and  white  matter,  but  especially 
of  the  soft  membranes.  If  the  cranium  be  opened  before  the  thorax, 
the  vessels  will  be  found  far  more  engorged  than  when  the  reverse  pro- 
cedure is  adopted,  whereby  opportunity  is  afforded  for  draining  off  the 
blood  from  the  head  through  the  large  vessels  so  severed  in  the  chest. 
As  to  the  results  of  intra-thoracic  pressure,  we  must  be  prepared  to 
find  engorgement  of  the  cerebral  vessels  in  the  pia  in  all  cases  of  severe 

*  "The  common  thickening  of  the  membranes  over  the  upper  surface  of  the 
brain,  increasing  towards  the  longitudinal  sinus,  is  explicable  by  the  mechanical 
congestion  that  must  be  favoured  there,  through  the  current  of  blood  from  the 
cerebral  veins  entering  the  longitudinal  sinus  against  the  course  of  the  stream 
within  the  sinus.  The  check  so  caused  to  the  entering  stream  will  have  most 
effect  on  the  part  of  the  stream  that  is  near  the  vein  wall,  for  this  is  weaker  than 
the  current  in  the  middle  of  the  vein,  but  this  parietal  layer  of  the  stream  receives 
the  blood  from  the  parts  near  the  sinus,  and  hence  these  will  feel  the  check  more 
than  the  distant  parts,  and  will  tend  to  be  held  all  one's  life  in  a  state  of  mechanical 
congestion  of  mild  degree  "  (Lectures  on  Analytical  Pathologij.     Moxou). 


446  TUB    MORDID    BRAIN    IX    INSANITY. 

obstruction  or  obliteration  of  the  pulmonary  blood-vessels — e.g.,  exten- 
sive new  growths  in  the  nicdiastiniun,  copious  pleuritic  elFusions,  con- 
striction   from,  various    causes    of    the    roots    of    the    lungs,    fibroid 
induration  of  lung,  kc.     Rokitansky  has  alluded  to  the  extremes  we 
occasionally  meet  with  of  this  obstructive  engorgement  of  the  cerebral 
membranes,  the  vessels  of  which  he  describes  as  forming  "  spirally- 
twisted  coils  and  intestine-like   circonvolutions."  *     Nor  is  this  any 
exaggeration  of  what  we  see  occasionally  in  asylum  practice.      We 
should  have  said  very  rarely,  for  but  three  such  cases  have  occurred  in 
our  experience  of  considerably  over  two  thousand  inspections.     Such,  for 
instance,  was  the  case  of  an  alcoholic  subject  suffering  from  fibroid  indu- 
ration of  the  lung,  and  in  whose  case  capillary  bronchitis  supervened, 
resulting  in  an  extremely-stupoi'ose  condition  for  days  together.     The 
necropsy  revealed  an  extraordinary  development  of  varices  and  con- 
torted vessels  in  the  membranes  actually  concealing  from  view  exten- 
sive areas  of  the  brain-surface ;  whilst  enormous  numbers  of  extrava- 
sations varying  from  miliary  and  punctiform  hcemorrhages  to  patches 
from  a  pea  to  a  florin  in  extent  were  scattered  throughout  a  deeply- 
congested  brain  both  in  grey  and  white  substance. f     To  a  much  less 
marked  degree  is  the  engorgement  recognised  in  obstructive  throm- 
bosis of  the  sinuses,  for  in  all  examples  met  with  we  have  found  the 
patency  of  the  channel  diminished  only  to  a  minor  extent  from  firm 
organisation   and    shrinking    of    the    clot.       Death   from    pulmonary 
gangi'ene  occasionally  occurs  as  the  result  of  such  clots,  or  portions 
of  such  dislodged,  passing  by  the  right  cavities  of  the  heart  into  the 
pulmonary  vessels.      The  result  of  contraction  of  a  limited  vascular 
area  of  the    cortex    upon    neighbouring   territories   must,    we   opine 
for  the  present,  be  a  moot  point ;  but  we  cannot  fail  to  regard  it  as 
highly  probable  that  any  such  limited  spasm  must  tell  in  an  exactly 
reversed    vascular    state    of    neighbouring    cortical    and    subcortical 
tracts.     The  cortical  nutrient  branches  form,  as  we  have  learnt  from 
M.  Duret,  an  absolutely-terminal  (non-anastomotic)  system  of  vessels, 
and  (counter  to  the  view  of  Heubner)  the  larger  branches  of  the  pia 
also  map-out  individualised  and  but  feebly  inter-communicating  terri- 
tories.    Hence,  we  have  reason  to  infer  that  each  terminal  system  is 
the  representative   of  a  neuro-vascular  autonomy ;   and  that  limited 
spasms  of  such  a  system,  whilst  raising  the  blood-pressure  generally 
throughout  the  periphery,  also  cause  increased  flow  to  neighbouring 
cortical  realms.     How  extremely  delicate  is  the  adjustment  so  aflected 
is  obvious  from  the  researches  of  Mosso,  who  remarked  that  in  the 

*  "  Pathological  Anatomj',"  Sydenham  Soc,  vol.  iv.,  pp.  372-3. 
t  See   also  a  similar  case  reported   in  the   Lancet  for  January  11,   1S79,  by 
Dr.  Coupland 


MORBID    VASCULARITY — CEREBRITIS.  447 

case  of  his  patient,  when  asleep,  the  slightest  sound,  such  as  the  tick  of 
a  watch,  oi'  a  spoken  word,  short  of  awakening  the  sleeper,  invariably 
caused  increased  vascularity  of  the  brain,  with  a  corresponding  fall 
of  blood-pressure  in  the  arm,  as  registered  by  the  plethysmography 
Such  an  observation  gives  us  a  graphic  illustration  of  what  is  con- 
tinually occurring,  during  the  normal  active  processes  in  our  conscious 
moments,  as  the  mere  result  of  sensory  excitations  alone. 

A  bright  red  blush  irregularly  distributed  in  patches  is  often 
observed  in  the  cortex  of  those  dying  insane,  a  rosy-tinted  mottling, 
stippled  here  and  there  with  the  orifices  of  larger  vessels  cut  across, 
and  defining  (in  most  cases  very  accurately)  the  limits  of  certain 
independent  vascular  tracts  or  plexuses.  It  is  more  frequently  an 
accompaniment  of  the  more  acute  forms  of  insanity,  and  we  hesitate  to 
attach  to  it  any  further  importance  than  as  indicating  the  severity  of 
the  late  functional  disturbance.  Certain  it  is  that  this  appearance  is- 
not  necessarily  correlated  with  any  obvious  structural  change  in  the 
part ;  nevertheless,  it  is  a  witness  to  the  storm  which  has  swept  past. 
We  have  suggested  elsewhere*  that,  "the  last  act  of  arterial  contraction, 
in  which  the  smaller  arterioles  have  failed  to  empty  themselves  into 
the  venous  system,  may  in  part  explain  this  appearance,"  and  have 
also  noted  how  "  this  blotchy  red  aspect  of  the  cortex  reappears  very 
fi'equently  in  the  medulla  in  similar  cases;"  and  we  still  regard  it  as 
l^robably  so  explained,  the  failure  to  contract  being  evidence  of  the 
paretic  state  of  the  vessel,  whilst  the  effect  of  limited  spasms  would 
from  our  former  remarks  be  still  more  likely  to  issue  in  this  blotchy 
mottling  of  the  cortex.  The  same  remarks  apply  to  the  rosy  vascular 
zones  which  so  frequently  present  themselves  along  the  junction  of  the 
white  and  grey  matter.  This  and  the  fourth  layer  are  usually  the 
sites  of  the  rosy  discoloration  now  alluded  to  ;  and  this  coincides  with 
the  results  of  imperfect  injections  of  the  cortex,  which  indicate  that 

the  long"  straight  vessels  and  their  horizontal  nexus  on  the 

confines  of  the  grey  are  the  most  readily  filled ;  next,  the  plexus 
around  the  cells  of  the  fourth  and  fifth  layers ;  and  lastly,  the  vascular 
plexus  in  the  third  and  the  first  layers  respectively.  We  have 
alluded  to  this  ready  filling  of  these  straight  vessels  of  the  medulla  as 
a  sort  of  safety-valve  action  for  relieving  the  cortex  from  undue  engorge- 
ment. The  rosy  mottling  of  the  medulla  is  again  a  frequent  accom- 
paniment of  the  foregoing  signs  where  such  cerebral  excitement  has 
preceded  death,  or  where  epilepsy  has  terminated  fatally  in  the 
''  status ;"  and  in  such  cases  it  is  interesting  to  note  the  comparative 
paucity  of  puncta  vasculosa  which  undoubtedly  (as  JSTiemeyer  has 
stated)  form  a  most  unsafe  criterion  to  accept  of  congested  states  of  the 
*  The  Human  Brain :  Methods  of  Examination,  p.  52, 


448  THE    MORIUI)     BRAIN'    IX    INSANITY. 

brain.*  Since,  then,  the  appoar.ajices  above  detailed  are  occasionally 
the  sequence  of  uther  tlian  lamhid  states,  how  are  we  to  deal  with 
their  significance  as  morbid  signs  1  The  reply  is,  in  the  presence  of 
minute  extravasations,  in  the  coarseness  or  evident  disease  of  the  small 
'vessels,  in  the  existence  of  much  ledema  of  the  tissues,  in  the  altered 
<consistence  and  specific  gravity  of  the  tissues;  all  of  which  afford 
indications  of  value  ere  we  resort  to  more  minute  histological 
examination. 

Increased  vascularity  is  by  no  means  the  more  frequent  appearance 
found  in  fatal  cases  of  insanity — in  acutely -maniacal  conditions,  and 
•especially  in  general  paralysis,  it  is  often  observed  ;  but,  by  far  the 
Jarger  number  of  cases  afford  evidence  of  poverty  of  blood  in  the  brain 
iind  general  malnutrition.  Thus  uniform  pallor  prevailed  as  a  note- 
•worthy  feature  in  841  cases  out  of  a  total  of  1565  autopsies,  or  consider- 
.ably  over  one-half  (53-7  per  cent.).  "What  was  stated  respecting  the 
independence  of  vascular  regions  of  the  brain  as  regards  both  the 
terminal  arterioles  and  the  larger  areas  mapped-off  by  the  distribution 
of  three  main  arteries  of  the  cerebrum,  is  illustrated  by  the  anaemic 
^states  of  the  cortex,  even  as  we  found  it  was  by  states  of  hypersemia. 
We  find  conditions  of  patchy  pallor  mottling  the  cortex,  or  a  uniformly 
diffused  pallor,  or,  not  by  any  means  infrequent  in  cases  of  melancholia, 
.a  notable  pallor  of  the  carotid  arete  associated  with  fulness  of  vessels 
both  of  the  white  and  grey  substance  in  the  vertebral  system 
^posterior  cerebral).  By  far  the  more  extreme  forms  of  antemia 
met  with  in  the  insane  are  cases  of  chronic  phthisis,  unfortunately  so 
frequent  in  asylums.  The  pallor  is  a  most  sti'iking  feature,  and  is  due, 
■of  course,  to  general  bloodlessness  throughout  the  system.  So  also  as 
the  result  of  severe  haemorrhage,  as  in  the  post-partum  haemorrhage 
-which  may  usher  in  puerperal  insanity,  this  condition  of  blanch- 
ing will  be  found  present.  Intracranial  pressure,  again,  such  as 
results  from  sanguineous  ajjoplexy,  the  presence  of  adventitious 
growths,  or  excessive  development  of  interstitial  connective  {neuroglia) 
may  all  lead  to  notable  anajmia  by  foix-ible  exclusion  of  blood  from 
the  cerebral  vessels ;  but,  here  the  blanched  aspect  of  the  surface  is 
associated  with  so  much  flattening  of  the  convolutions  that  the 
conditions  are  at  once  appreciated. 

Inflammation. —Acute  cerebritis  as  a  diffuse  afl'ection  of  the 

brain  we  have  had  no  experience  of  amongst  the  insane;  on  the  other 
Land,  as  a  localised  condition  due  to  focal  lesion,  it  is  by  no  means 
uncommon,  whilst  a  chronic  meningo-cerebritis  is  also  of  very  frequent 
occurrence.  To  take  the  more  acute  process  first,  we  usually  find  it  as 
ihe  result  of  an  emholon  or  thrombus  of  a  cerebral  blood-vessel,  which 
*  Text-hook  of  Medicine,  Niemcyer. 


INDICATIONS    OF    CEREBRITIS.  449 

has  given  rise  to  much  punctiform  haemorrhage  around,  or  to  hfcmor- 
rhagic  foci  in  the  cortex  or  ganglia;  or,  again,  to  the  presence  of  new- 
growths,  such  as  carcinoma  or  tubercle,  which  are  frequently  surrounded 
by  a  zone  of  red  inflammatory  softening,  beyond  which  extends  a 
further  non-inflammatory  zone  of  simple  white  or  yellow  softening. 
The  cerebral  tissue  so  involved  is  swollen,  distinctly  cedematous,  and 
variable  in  its  consistence  up  to  the  extreme  degrees  of  difiiuence ;  it  is 
usually  of  bright  pink  hue,  with  streaky  or  punctated  haemorrhages 
scattered  throughout  its  texture. 

The  inflamed  tissue  may  show  little  or  no  discoloration,  in  fact  this 
is  very  frequently  the  case ;  but  in  all  instances  we  find  the  presence  of 
inflammatory  exudates  modifying  the  appearance  and  textural  con- 
tinuity of  the  part,  presenting  compound  granule-cells,  nuclei,  leucocytes, 
broken-down  nerve-structures  and  pigment;  whilst  the  specific  gravity 
will  be  invariably  augmented  by  the  inflammatory  exudation  present. 
In  the  immediate  neighbourhood  of  such  inflammatory  patches  we  often 
find  the  tissue  in  a  state  of  white  or  yellow  softening,  non-inflammatory 
in  character;  in  fact,  due  to  interference  with  the  nutrient  supply  of 
the  part,  to  plugging  of  the  minute  vessels,  or  to  direct  pressure  of  the 
swollen  cedematous  tissue  around  the  inflamed  focus.  There  is  no 
causal  connection  betwixt  such  states  of  inflammatory  softening  and 
insanity;  they  occur  as  accidents  in  the  course  of  certain  vascular 
diseases  associated  with  mental  disease,  and,  therefore,  it  is  necessary 
to  allude  to  them  here.  Far  otherwise  is  it  with  the  chronic  inflamma- 
tion of  brain  and  membranes  which  is  intimately  related  to  the  insidious 
and  fatal  malady,  general  paralysis.  In  this  form  of  chronic  meningo- 
cerebritis  the  inflammatory  changes  begin,  probably,  at  several  difierent 
points,  spreading  from  one  convolution  to  another,  until  in  many  cases 
the  whole  cerebral  mantle  is  involved,  with  the  exception  of  the 
occipital  gyri,  which  almost  invariably  escape  implication.  The 
progress  of  inflammatory  activity  is  usually  most  marked  in  the  frontal 
regions  in  both  hemispheres,  and  less  advanced  in  the  parietal.  The 
cortex  is  much  thinned  in  the  fronto-parietal  region,  and  of  very 
variable  colour,  frequently  exhibiting  the  irregular  mottled  aspect 
from  pinkish  discolorations  or  congested  patches,  but  also  quite  as 
often  pale  grey,  or  of  a  uniform  dirty  grey  hue  with  but  poorly-defined 
lamination.  The  arterioles  of  the  cortex  are  frequently  and  notably 
coarse  and  engorged.  The  substance  of  the  cortex  is  much  reduced  in 
consistence,  and  cedematous;  the  whole  brain  is  softened,  and  has  an 
ill-nourished  look;  in  fact,  apart  from  the  firm  inflammatory  adhesion 
of  the  opaque  and  thickened  membranes,  the  naked-eye  appearances  of 
the  cortex  are  not  unlike  an  extremely  ill-nourished  and  atrophied 
brain  in  old  age,  presenting  in  itself  no  characteristic  indications  of  the 
extensive  inflammatory  changes  which  it  has  undergone. 

29 


450  THE    MORBID    BRAIN    IN    INSANITY. 

Softening". — Out  of  853  cases  of  insanity  proving  fatal,  390  afforded 
insUmces  of  an  increasetl  consistence  of  brain  or  one  of  average  tirin- 
ness ;  the  remainder  were  noted  as  having  a  diminished  consistence 
throughout.     The  actual  figures  were  as  follows  : — 

Increased  consistence  throughout  ....  98  cases. 

Firm  consistence  ,,  .         ,         .         .  110     ,, 

Fair  or  average  consistence  ,,  .         .         .         .  182     ,, 

Diminished  consistence         ,,  .         .         .         .  463      ,, 

Roughly  speaking,  therefore,  close  upon  one-half  (or  45  7  per  cent.) 
were  of  normal  consistence  or  above  the  usual  degree  of  firmness — the 
remaining  54*2  per  cent,  being  softened,  either  as  the  result  of  disease 
or  of  post-mortem  change.     As   a   fact,   however,   a   state  of  general 
reduced  consistence,  apart  from  any  putrefactive  process,  prevails  in  a 
large  percentage  of  cases ;  and  this  is  accounted  for  by  the  large  pro- 
portion of  cases  of  senile  atrophy,  of  general  paralysis,  and  of  organic 
brain-disease  (the  result  of  diseased  arteries)  which  accumulate  in"  our 
asylums  and  form  so  large  a  fraction  of  the  fatal  cases.     The  general 
diminution  in  cerebral  consistence  may  be  due  to  oedema  of  its  texture, 
as  the  grey  matter  has  notable  hygrometric  powers;  it  may  be  due  to  dis- 
integration of  structure  from  the  fatty  degeneration  of  senility,  or  from 
extensive  vascular  disease  restricting  its  nutrient  supply,  or  it  may  be 
the  result  of  inflammatory  processes.     In  all  cases  we  observe  that  the 
vascular  system  is  largely  involved.     The  oedema  is  first  established 
by  the  undue  engorgement  of  vessels  which  thus  relieve  themselves 
(not  only  in  congestive  and  inflammatory  processes,  but  also  in  the 
atrophy  resulting  in  the  so-called  hydrops  ex  vacuo);  the  fatty  disinte- 
gration   of  senile    brain    is    invariably    associated   with,   and    greatly 
furthex'ed  by,  diseased  arterial  tunics ;  and,   lastly,   the  inflammatory 
processes,  which  ai-e  of  a  chronic  diffuse  nature,  are,  we  believe,   in 
themselves  vascular  in  their  origin.     Hence  we  see  bow  large  a  section 
of  the  insane  show  indications  of  defective  nutrition  in  the  central 
nervous  system,  and  derangements  of  its  blood  supply ;  yet  acute  or 
recent   insanity  affords   few  and    far  less  pronounced   signs  of  such 
impairment.     It   is    in   the    chronic    stage    of  insanity    that    obvious 
structural  changes  indicate  to  us  the  serious  nature  of  the  nutritive 
failure.     In  instances  of  general  reduction  in  the  consistence  of  the 
brain,  the  organ  fails  on  removal  to  maintain  its  erect  position  ;  it  falls 
apai't  at  the  commissural  junctions,  the  diverging  hemispheres  tending 
by  the  mere  effect  of  gravity  to  tear  the  latter  asunder,  especially  as  these 
commissures  are  themselves  unduly  soft.     The  hemispheres  have  lost 
their  plump  contour ;  the  convolutions  may  have  undergone  consider- 
able atrophy,  and  their  widely-gaping  sulci  may  enclose  much  serous 


CEREBRAL    SOFTENING.  451 

fluid  ;  whilst  the  whole  brain  feels  flahby  to  the  touch,  and  devoid  of 
its  normal  compact  aspect,  as  well  as  of  the  firm  and  resilient  feel  of 
iiealthy  structure.  In  the  ventincles  we  often  find  considerable  serous 
fluid  unduly  distending  these  cavities,  whose  walls  have  a  macerated 
aspect,  and  are  undergoing  rapid  solutions  of  continuity.  The  white 
substance  may  have  a  glairy,  brilliant  aspect,  be  much  softened  in 
texture,  pit  on  pressure,  whilst  few  or  no  puncta  vasculosa  appear,  the 
vessels  being  compressed  by  the  swollen  (edematous  structure  around  ; 
or  it  may,  on  the  other  hand,  have  a  dull,  lack-lustre  surface,  mottled 
with  difi'used  congested  zones,  stained  with  hsematine,  and  presenting 
numerous  coarse  and  bristly  vessels. 

In  extreme  cases  of  white  softening,  however,  the  brain-substance 
may  be  completely  diffluent  here  and  there,  and  present  to  the  touch 
a  semi-fluctuating  feel,  breaking  up  readily  upon  manipulation ;  its 
central  parts — the  fornix,  septum  pellucidum,  and  commissure — being 
more  or  less  wholly  disintegrated.  Such  localised  softenings  super- 
added to  the  more  generally  diffused  form  above  described,  are  due  to 
the  association  of  plugging  of  the  cerebral  blood-vessels  by  thrombus  or 
embolon.  The  substance  of  the  brain  thus  implicated  may  be  reduced 
to  a  soft,  pappy,  cream-like  fluid ;  or  the  almost  diffluent  medulla  may 
wash  away  in  this  form  by  the  impact  of  a  gentle  stream  of  water. 
Localised  softenings,  as  the  result  of  thrombosis  or  embolism,  frequently 
illustrate  to  us  the  regional  autonomy  of  the  cerebral  blood-vessels  by 
invading  only  the  district  of  supply  of  one  of  the  principal  branches  of 
the  three  large  vessels  of  the  cerebrum ;  and  thus  we  may  have  lesions 
of  one  of  three  districts  of  the  anterior,  or  of  the  posterior  cerebral, 
or  one  of  the  four  districts  of  the  middle  cerebral,  exclusively,  or 
variously  associated. 

In  this  connection  undoubtedly  the  area  of  supply  of  the  middle 
cerelDPal  is  far  the  more  frequently  afi'ected ;  next  to  this,  but  with 
far  less  frequency,  the  posterior  cerebral  areas  sufier ;  and  least 
frequently  of  all,  the  areas  supplied  by  the  anteriOP  Cerebral.  The 
relative  implication  of  the  various  branches,  or  rather  their  territories 
of  distribution,  are  for  the  middle  cerebral  or  Sylvian  trunk  as  follows 
(the  more  frequently  implicated  branches  in  order  of  precedence) : — 
Parieto-sphenoidal,  ascending  frontal,  ascending  parietal,  external  and 
inferior  frontal  branches.  For  the  posterior  cerebral  the  order  of 
precedence  is — first,  the  occipital  branch,  and,  far  less  frequently,  the 
two  anterior  branches  to  the  uncinate  and  fusiform  gyri.  Again,  for 
the  anterior  cerebral  the  order  of  precedence  in  morbid  implication 
is — the  middle  and  external  frontal  branch,  the  anterior  and  internal 
frontal,  and,  least  frequently,  the  posterior  and  internal  branch.  This 
may  be  more  clearly  represented  in  the  following  tabulation — 


452 


THE    MORBID    HHAltf    IN    INSANITY. 


Anterior  Cerebral.  Miildle  Cerebral. 

Middle  and  internal  frontal  I'arieto-splienoiclal  artery. 

artery.  Ascending  frontal        ,, 

Anterior       .,        ,,         ,,  Ascending  parietal      ,, 

Posterior      ,,        ,,         ,,  Kxternal  and  inferior  frontal 


Posterior  Cerebral. 
Occipital  artery. 
Anterior  and  posterior 
temporal  artery. 


Fig.  10. — Illustrative  of  the  more  frequent  site  of  localised  soften ingsTin 
order  of  precedence. 

In  149  cases  of  localised  lesions,  the  convolutions  most  frequently 
affected,  and  medullated  centrum  would  run  as  follows  in  like  order  of 
precedence : — 

1.  Upper  temporo-sphenoldal  gyrus. 

2.  Occipital  and  cuneate  ,, 

3.  Ascending  frontal  ,, 

4.  Postero-parietal  ,, 

5.  Centrum  ovale  =  not  defining  as  to 

anterior  or  middle  frontal  territory. 


6.  Annectants. 

7.  Angular  and  supramarginaL 

8.  Orbital. 

9.  Insula  and  operculum. 

10.  Fusiform  and  uncinate. 

11.  Gyrus  fornicatus  and  quadrate. 


Fig.  11. — Illustrative  of  the  more  frequent  site  of  localised  softenings  in 
order  of  precedence. 


LOCALISKD    SOFTENING. 


453 


A  further  analysis  of  166  cases  of  localised  or  focal  softenings  (due 
either  to  thrombosis,  embolism,  or  to  haemorrhage)  in  the  substance  of 
the  basal  ganglia,  and  their  medullated  capsules  indicate  the  respective 
proclivity  to  such  lesions  in  the  insane  to  be  as  follows : — The  lej'l 
hemisphere  is  in  all  instances  of  ganglionic  lesion,  slightly  more  prone 
to  implication;  the  intraventricular  nucleus  is  far  the  more  frequently 
affected,  the  optic  thalamus  comes  next  in  frequency,  but  the  pro- 
portion does  not  rise  beyond  two-thirds  the  latter;  the  extraventricular 
or  lenticular  nucleus  is  somewhat  less  frequently  involved  than  the 
optic  thalamus ;  lastly,  the  two  capsules,  external  and  internal,  are 
far  less  often  implicated,  and  of  these  the  inner  shares  the  greatest 
immunity. 


Fig,  12. — Illustrative  of  the  luoic  ire^uent  site  of  localised  softenings  in 
order  of  precedence. 

Of  the  166  cases  of  softening  from  which  these  data  are  obtained, 
thirty-four  were  instances  of  hfemorrhage,  and  the  remaining  number 
were  the  results  of  clot,  usually  thrombosis.  The  results  agree,  therefore, 


454  THE    MORBID    BRAIN    IN    INSANITY. 

in  every  particular  with  those  arrived  at  from  a  study  of  the  locality 
of  cerebral  lijemorrhage,  for  it  has  been  shown  by  Andral  and  Durand- 
Fardel,  that  the  corpora  striata  are  more  frequently  the  site  of 
haemorrhage  than  the  thalami ;  and  Charcot  expresses  his  opinion  that 
next  to  the  opto-striate  bodies,  the  claustrum  is  the  more  frequent 
site  of  lesion.*  Whatever  be  the  origin  of  the  cerebral  lucmorrhages 
met  with  in  the  insane  (whether  the  result  of  a  periarteritis  or  an 
endarteritis),  this  we  can  safely  affirm,  that  the  same  systems  of 
vessels  have  the  same  relative  liability  to  suffer  in  cases  of  softening, 
following  occlusion  from  thrombosis,  as  in  cases  of  haimoiTliagic  foci. 

Atrophy. — Wasting  of  the  grey  and  white  meduUated  structures 
of  the  brain  is  of  very  frequent  occurrence  in  insanity,  but  it  is  as  a 
sequel  to  the  acute  forms ;  and,  in  the  chronic  forms  of  insanity,  such 
atrophy  is  seen  to  invade  these  structures  to  an  extensive  degree.  It 
may  be  general  throughout  the  cerebral  hemispheres,  whilst  the  basal 
ganglia  and  mesencephalon  escape  implication ;  but,  occasionally,  the 
whole  of  the  intracranial  ganglia  are  involved.  On  the  other  hand, 
it  may  be  localised  or  pa7'tial,  when  it  may  implicate  any  region  of  the 
brain.  It  may  be  rapidly  induced  as  the  result  of  an  inflammatory 
process ;  or  it  may  be  of  extremely  sloio  and  insidious  progress  ;  or  the 
steady  progressive  dissolution  implicating  the  whole  cerebrum,  which 
distinguishes  the  atrophy  of  premature  senility.  The  intimate  structure 
of  the  centi'al  nervous  system  would  indicate  peculiar  relationships  as 
established  betwixt  the  individual  elements  which  must  be  fully  recog- 
nised ere  we  clearly  appreciate  the  significance  of  these  various  forms 
of  atrophic  change.  Let  us  take  as  illustration  of  our  remarks  the 
district  supplied  by  one  of  the  terminal  cortical  arteries.  Now,  we 
affirm  that  the  autonomy  of  this  department  demands  a  mutual  sym- 
pathy betwixt  all  the  constituent  elements  of  the  same  ;  in  other  words, 
action  and  reaction  is  so  established  between  them  that  any  derange- 
ment in  the  functional  activity  of  the  one  must,  of  necessity,  affect  the 
other.  In  fact,  the  more  highly  differentiated  the  structural  parts  of  a 
tissue  become,  the  moi'e  dependerd  also  do  they  mutually  become.  It 
matters  little  for  this  terminal  arterial  territory  if  a  distant  branch 
(however  large)  off  the  same  trunk  be  plugged,  it  still  maintains  its 
autonomy;  but  it  matters  veiy  much  if  this  minute  branch  itself  be 
obstructed.  The  nerve-cell  is  dependent  upon  the  terminal  artery  for 
a  due  supply  of  its  nutrient  plasma ;  the  artery,  in  its  turn,  is  regu- 
lated as  to  its  calibre  by  the  functional  activity  of  the  nerve-cell ;  the 
lymph-connective  system  of  the  neuroglia  is  stimulated  to  renewed 
activity    by   the  accumulating  i)roducts   of  nerve  disintegration  ;  the 

*  Localisation  in  Cerebral  Diseases. 


CEREBRAL    ATROPHY.  455 

nervous  elements  depend  upon  this  continuous  removal  of  effete 
material  for  their  normal  storage  and  discharge  of  energy  ;  and  so,  in 
like  manner,  the  connective  and  vascular  elements  are  mutually  de- 
pendent. In  no  organ  of  the  body  is  this  mutual  dependence  of  parts 
so  exquisitely  elaborated  as  in  the  brain  and,  a  fortiori,  the  cerebral 
cortex.  Terminal  vessels  exist  elsewhere,  as  in  the  spleen,  kidney, 
and  lung ;  but  the  presence  of  the  nervous  element  establishes  a  much 
more  complete  mutual  dependence  of  parts.  This  inter-dependence  of 
the  sti'uctural  elements  of  the  cortex,  due  to  its  terminal  system  of 
arteries,  is  of  primary  importance  to  us  in  correctly  appreciating  the 
morbid  appearances  presented  in  insanity.  Another  factor,  however, 
must  be  invariably  considered  with  respect  to  all  morbid  lesions  of  the 
cortex,  and  that  is  the  sympathy  betwixt  distant  territories  which 
ai'e  functionally  associated  in  their  activities,  and  structurally  linked 
together  by  "association"  fibres.  The  former  condition — the  inter- 
dependence of  parts  in  terminal  systems — was  the  direct  outcome  of 
elaborate  differentiation ;  the  latter  condition  of  sympathy  betwixt 
distant  territories  is  established  by  an  equally  elaborate  structural 
integration. 

Keeping  these  facts  in  view,  it  becomes  obvious  that  much  obscurity 
naturally  overshadows  many  pathological  processes  in  the  cortex 
cerebri,  despite  the  prominence  of  the  morbid  changes  presented.  No 
one  element  of  the  tissue  of  the  cortex  can  suffer  materially,  without 
rapidly  disturbing  the  nutritive  equilibrium  consistent  with  the  health 
of  the  territory  to  which  it  is  attached ;  hence  it  often  becomes  a 
question  whether  changes  observed  in  the  nerve-cells  are  evidence  of 
primary  implications,  or  whether  they  are  secondarily  induced  through 
a  disturbance  in  the  circulation  of  the  district,  or  impairment  of  the 
lymphatic  functions  of  the  cortex,  in  a  blood  crasis,  or  other  cause;  or, 
again,  as  in  the  medulla,  whether  a  sclerosic  change  with  atrophy  of 
nerve-tubuli  is  primarily  pai-enchymatous  (originating  in  the  nervous 
element),  or  interstitial  (sj^reading  from  the  neui'oglia  to  the  latter). 
There  is  every  reason  to  believe  that  in  the  nervous  centres  both 
parenchymatous  and  interstitial  change  may  occur  as  the  primary  fact ; 
that  the  nerve-cell,  for  instance,  may  be  stamped  with  a  morbid  insta- 
bility wholly  independent  of  any  ab  extra  agency,  and  this  as  an 
inherited  or  as  an  acquired  condition ;  nor  is  it  unreasonable  to  sup- 
pose that  the  changes  iu  the  nerve-cell  in  physiological  senescence 
are  initiated  apart  from  any  nutritive  anomalies  and  blood  vascular 
changes,  being  simply  the  expression  of  the  expiration  of  its  fixed  term 
of  existence. 

The  very  general  atrophy  of  the  cei'ebral  cortex  occurring  in  patho- 
logical senescence  is  often,  but  by  no  means  invariably,  associated  with 


456  THK  Monnin  rijain  in  insanity. 

a  degeneration  of  its  nutrient  vf;ssels,  and  wlien  these  vessels  are 
involved  it  is  to  a  very  varying  degree.  Yet  what  is  invariably  foiind 
is  the  degeneration  of  the  nerve-cells  which,  in  any  appreciable  degree 
of  atrophy,  are  extensively  and  very  notably  implicated.  We  have 
here,  in  fact,  what  may  be  regarded  as  a  true  parenchymatous 
degeneration ;  the  primary  change  is  initiated  in  the  nerve-cell. 

Other  forms  of  atrophy,  usually  more  limited  in  distribution,  occur 
as  the  result  of  over-action  of  nervous  centres;  in  such  cases  the  element 
which  chiefly  assumes  the  morbid  rdle  is  the  connective  matrix  or 
neuroglia,  although  the  primary  incitant  was  undoubtedly  nervous. 
Illustrations  are  afforded  in  the  case  of  alcoholism,  where  repeated 
over-stimulation  of  nervous  elements  and  the  waste  and  eflete  material 
so  produced,  demand  from  the  lymph-connective  system  more  than  its 
capabilities  can  accomplish;  the  result  is  a  temporary  hypertrophy 
of  this  tissue,  the  multiplication  of  its  active  elements  {phaijocytes) 
followed  by  their  fibrillation,  and  the  eventual  atrophy  due  to  the 
encroachments  of  the  connective  upon  the  nervous  elements.  A 
different  illustration  is  afforded  by  cases  of  epileptic  insanity,  for  here 
again  over-action  leads  to  degeneration  and  atrophy  of  nerve-cells 
through  the  medium  of  an  encroaching  connective;  the  conditions  of 
the  epileptic  are,  however,  by  no  means  parallel  to  the  alcoholic,  and 
we  find  that,  in  lieu  of  actual  atrophy  of  the  brain-mass,  there  is  often 
hypertrophy  and  augmented  density  due  to  the  inordinate  growth  of 
the  connective  element.  Instances  of  premature  senility  (or  what 
used  to  be  called  atrophia  cerebri  precox)  are  illustrative  of  this  form 
of  atrophy  from  over-activity  of  nervous  centres.  Long  continued  or 
oft  repeated  excitement  induces  a  similar  state  of  atrophy,  as  seen  in 
most  fatal  cases  of  chronic  insanity. 

A  frequent  cavise  of  localised  shrinking  of  the  brain-substance  is  the 
destruction  and  cicatricial  condensation  of  tissue  in  hemorrhagic  foci; 
or,  again,  as  the  result  of  inflammatory  destruction  of  nervous  tissue, 
whether  arising  centrally  or  spreading  inwards  from  the  meninges. 
Either  of  these  affections  occurring  in  infancy  will  almost  certainly, 
owing  to  the  principle  enunciated  above,  retard  the  development  of 
distant  parts,  so  that  in  adult  life  the  brain  will  exhibit  great  disparity 
in  its  two  hemispheres,  and  in  different  regions  of  the  afiected 
hemisphere.  Such  cases  also  illustrate  the  crossed  connection  betwixt 
cerebrum  and  cerebellum,  and  between  the  cerebellum  and  the  opposite 
olivary  body,  such  as  have  been  indicated  by  Van-der-Kolk  and 
Aleynert.  As  illustrative  of  this  condition,  may  be  mentioned  the  case 
of  a  paralytic  idiot,  the  subject  of  right  hemiplegia  and  epilepsy,  who 
died  at  the  West  Riding  Asylum,  and  in  whom  there  was  found 
atrophy,  with  sclerosis  of  the  left  cerebral  hemisphere,  associated  with 


CEREBRAL    ATROPHY. 


457 


atrophy  of  the  right  lobe  of  the  cerebellum  (Major) ;  *  also  the  case  of 
another  patient  at  this  asylum,  in  which  a  lesion  of  one  hemisphere 
of  the  cerebellum,  of  the  nature  of  an  old  htemorrhagic  cavity  with 
dense  sclerous  walls  implicating  the  corpus  dentatum,  was  associated 
with  degeneration  of  the  olivary  body  of  the  opposite  side  (Dudley),  f 

The  frequency  of  atrophy  of  the  cerebral  hemispheres  in  insanity, 
may  be  conclusively  shown  by  the  post-mortem  statistics  afforded  at  the 
West  Riding  Asylum.  It  is  hereby  shown  that,  out  of  a  total  of  1,565 
fatal  cases  of  all  forms  of  insanity,  as  many  as  1,055  (or  67'4  per  cent.) 
presented  evidence  of  cerebral  atrophy;  that  the  wasting  was  general 
throughout  the  hemisphere  in  574  of  these  cases,  although  261  also 
exhibited  a  special  implication  of  certain  areas,  and  that  in  481  other 


Fig.  13. — Illustrative  of  the  sites  of  election  of  atrophy  in  order  of  precedence. 

cases  partial  or  localised  atrophy  was  observed.  The  fronto-parietal 
segment  of  the  hemispheres  enjoys  least  immunity  from  the  atrophy 
incident  to  insanity,  and  we  find  atrophy  confined  to  the  frontal  lobes 
in  a  large  number  of  cases,  in  fact,  in  the  proportion  of  three-fourths  to 
one-fourth  respectively.  Of  still  more  restricted  areas  the  postero- 
parietal  lobule  appears  most  prone  to  a  localised  atrophy  (forty  cases); 
the  central  gyri  ranking  next  to  this  lobule  in  the  frequency  of  their 
implication  (thirty-seven  cases) ;  the  separate  frontal  gyri  and  Sylvian 
boundary  (operculum)  were  thus  affected  in  thirty-three  and  twenty- 

*  See  descriptive  summary  with  illustrations  of  this  case  by  Dr.  H.  C.  Major, 
Jovr.  Mental  Sc,  July,  1879. 

t  See  report  with  illustrations  by  Dr.  William  Dudley,  Jotir.  Mental  Sc, 
July,  1886. 


458  TUE    MOUUID    IJIiAIN    IN    INSANITY. 

nine  cases  respectively;  then  followed  the  temporo-sphenoidal  and  the 
occipital  gyri,  the  an<;ular  being  implicated  in  but  eight  cases.  The 
general  results  arrived  at  by  a  large  series  of  weights  of  the  brain  in 
the  insane,  excluding  cases  of  congenital  defect,  teach  us  that  the 
lowest  average  weight  due  to  atrophy  is  attained  by  instances  of  so- 
called  organic  dementia  (hajmorrhagic  or  ischaiuiic  softenings);  senile 
atrophy  of  the  brain  follows  next;  whilst  general  paralysis  ranks  third 
in  order. 

Miliary  Sclerosis. — So  frequently  has  the  lesion,  to  which  this 
term  is  applied,  been  recognised  as  occurring  in  the  central  nervous 
system  of  those  dying  insane,  since  it  was  first  described  and  figured 
by  Drs.  Batty  Tuke  and  Rutherford  in  1868,  that  we  feel  diflBdent  in 
suggesting  a  new  name ;  although  we  diflei-  from  those  observers  in 
regarding  its  nature  as  that  of  genuine  sclerosis  or  overgrowth  of  the 
connective  element  of  the  nervous  tissues.  That  the  morbid  change 
hitherto  recognised  under  this  term  must  eventually  ])e  renamed  we 
are  confident ;  and  that  when  its  nature  is  fully  understood  its  impor- 
tance will  gain  for  it  much  greater  attention  than  it  has  hitherto 
received  we  are  equally  confident ;  meanwhile,  we  retain  the  name 
whereby  it  has  been  known  for  the  past  twenty  years,  as  the  least 
likely  to  mislead  the  student  as  to  the  change  to  which  we  refer. 
The  morbid  appearance  presented  by  this  lesion  has  been  the  subject 
of  frequent  examination  by  many  observers,  but  little  (if  anything) 
has  been  added  to  the  graphic  account  given  by  its  discoverers.* 
Some,  however,  have  gone  the  length  of  denying  its  ])athological 
origin,  asserting  it  to  be  a  jjost-mortem  change  or  an  artificial  product 
cleverly  manufactured  by  the  histologist's  reagents  :  amyloid,  colloid 
bodies,  and  "miliary  sclerosis,"  have  all  in  their  turn  been  explained 
away  by  some  as  the  results  of  alcohol  or  other  reagents.  Unfortunately 
for  this  theoi'y,  however,  all  such  changes  are  to  be  found  in  the 
perfectly-fresh  brain  before  any  reagent  has  been  applied,  and  it  requires 
but  a  short  experience  in  the  fresh  preparation  of  nervous  structures 
amongst  the  insane  to  vindicate  their  pathological  import.  Dr.  Batty 
Tuke's  description  of  the  fully-developed  lesion  is  as  follows  : — 

"As  a  rule,  the  spots  are  unilocular,  occasionally  bilocular,  and  in  rare  instances 
multilocular  ;  but  whatever  their  condition  m  this  respect  is,  they  possess  the  same 
internal  characteristics.  A  thin  section  prepared  in  chromic  acid  viewed  by  the 
naked  eye  shows  a  number  of  opaque  spots  irregularly  distributed  over  the  surface 
of  the  white  matter  ;  they  are  best  seen  in  a  tinted  section,  as  they  are  not  colour- 

*  See  especially  Dr.  Batty  Tuke's  article  on  the  "  Morbid  Histology  of  tlie 
Brain  and  Spinal  Cord  in  the  Insane,"  Brit,  and  For.  Medko-Chlr.  Review,  July, 
1873  ;  also  Dr.  Kesteven's  paper  in  the  Brit,  and  For.  Medico-Chir.  Review,  April, 
1869. 


■pinal    cord   formiTi^ 


^^^T^ 


/  .* 


^ 


i    -^yAb 


MILIARY    SCLEROSIS.  459 

able  by  carmine.  When  magnified  by  a  low  power  they  have  a  somewluit  luminous 
pearly  lustre,  and  when  magnified  2ii0  and  800  diameters  linear,  they  are  seen  to 
consist  of  molecular  material,  with  a  stroma  of  exceedingly  delicate  colourless 
fibrils.  They  possess  a  well-defined  outline,  and  the  neighljouring  nerve-fibres  and 
blood-vessels  are  pushed  aside,  and  curve  round  them.  In  well-advanced  cases  the 
plasm  seems  denser  at  the  circumference  of  the  spots  than  at  their  centre,  and  a 
degree  of  absorption  of  the  contiguous  nerve-fibres  is  evident ;  this  solution  of  con- 
tinuity is  only  noticeable  at  the  point  where  the  lateral  expansion  is  greatest.  The 
spots  are  generally  colourless,  but  in  some  instances  they  are  of  a  yellowish-green 
tint,  which  may  be  attributable  to  chromic  acid.  They  vary  much  in  size  ;  uni- 
locular patches  are  -s^jjth  of  an  inch  to  rJuth  of  an  inch  in  diameter,  the  multilocular 
from  over  vr^th  to  ^^th  of  an  inch.  As  many  as  eleven  locules  have  been  noticed 
in  one  patch,  separated  one  from  the  other  by  fine  trabecular  of  nervous  tissue."  * 

The  favourite  sites  of  election  for  the  development  of  these  morbid 
appearances  seem  to  be  the  white  matter  of  the  cerebrum,  the  pons  and 
medulla,  and  the  lateral  columns  of  the  spinal  cord.  In  the  last  posi- 
tion it  can  be  studied  to  best  advantage,  although  it  is  far  more 
generally  met  with  in  the  medulla  of  the  cerebral  hemispheres.  When 
its  occurrence  is  noted  in  the  brain,  we  find  that  on  holding  up  a 
stained  section  slightly  aslant  to  the  light,  numerous  little  bright 
pellucid  points  appear  scattered  through  the  medullated  structure,  and 
just  perceptible  to  the  naked  eye ;  they  are  also  seen  by  reflected  light, 
but  not  by  direct  transmitted  light.  Under  a  low  power  each  of  these 
brilliant  points  is  resolved  into  a  distinctly  lobulated  patch  some  20  /a 
to  50  fjj  in  diameter,  their  colourless  aspect  strongly  contrasting  with 
the  stained  tissues  in  which  they  are  imbedded.  At  first  sight  they 
look  like  a  number  of  unequal  sized  droplets  of  a  fluid  of  somewhat 
dense  unctuous  consistence,  which  have  incompletely  fused  with  each 
other ;  and  which,  with  somewhat  oblique  light,  stand  ovit  in  bold 
relief  with  opalescent  or  frosted  pearly  lustre.  By  direct  light  they 
appear  more  translucent,  and  often  seem  like  unequally  lobulated 
cavities  (in  some  cases  actually  being  so,  the  contents  having  fallen 
out  during  the  pi-eparation  of  the  specimen).  They  present,  moreover, 
three  suggestive  features  which  have  a  direct  bearing  on  the  question 
of  their  pathogenesis. 

{a.)  They  are  distinctly  limited  to  the  white  meduUated.  Structure 
of  the  brain ;  and,  where  they  approach  the  grey  cortex  of  tlie  con- 
volutions, they,  in  most  cases,  ahrujylly  terminate,  the  naked-eye  suflUces 
to  elicit  this  limitation.  When  they  do  invade  the  cortex,  as  very 
rarely  occurs,  it  is  only  in  its  lowermost  zone,  and  then  strictly  along 
the  line  of  the  large  medullated  radiations. 

{b.)  The  perivascular  nuclei  frequently  exhibit  abundant  proliferation 
and  granular  hivmatoidin  masses  freely  cover  the  shoatli  of  the  vessel. 

*  Loc.  cit.,  p.  '205. 


460  THK    MORBID    RRAIN    IN    INSANITY. 

(e.)  The  condition  is  at  a  certain  stiige  invariably  associated  with  an 
increase  of  the  so-called  spider-cells  or  Deiter's  corpuscles. 

If  the  spinal  cord  rather  than  the  brain  be  the  subject  of  our 
scrutiny,  we  tind  the  lesion  presents  still  more  prominent  and  obtrusive 
indications  of  its  presence.  Its  demonstration  is  not  only  facilitated 
by  certain  features  here  presented,  but  the  essential  nature  of  the 
change  also  becomes  clearly  evident.  On  examining,  by  unaided 
vision,  a  stained,  transverse  section  of  a  spinal  cord  so  affected,  we 
find  a  dark-stained  area  (undoubtedly  sclerosic  in  nature)  of  one  or 
both  lateral  columns  ajyjyarently  riddled  by  numerous  minute  aper- 
tures ;  in  reality,  they  are  not  apertures,  but  minute  foci  readily 
transmitting  light,  owing  to  their  altered  tissue  and  resistance  to  all 
staining  reagents.  We  have  here,  in  fact,  a  system-disease  of  the 
cord — a  lateral  sclerosis  with  certain  peculiar  morbid  features  super- 
added. 

At  the  site  of  these  apparent  apertures  the  microscope  reveals 
colourless  translucent  patches,  irregular  in  contour,  usually  more  or 
less  lobulated,  and  frequently  showing  in  their  midst  indications  of 
varicose  medullated  fibres ;  reproducing  in  other  respects  the  appear- 
ances above  described  in  the  miliary  patches  of  the  brain.  Around 
such  unstained  areas  the  tissue  is  always  condensed  and  most  deeply 
stained,  and  the  nerve-elements  are  much  wasted  or  completely 
replaced  by  sclerosed  tissue  [PI.  \\.,fig.  1).  Far  more  instructive  speci- 
mens, however,  are  obtained  from  longitudinal  sections  through  the 
diseased  columns.  The  morbid  product  is  then  seen  to  be  aggregated 
in  oval  or  elongated  elliptic  patches  measuring  139  /a  to  186  /i  in  length 
by  40  /A  to  70  /A  in  breadth  ;  and  in  many  cases  the  morbid  material 
has  dropped  out,  leaving  only  an  irregular  opening,  the  boundaries  of 
which  are  fibrillated  and  never  clean-cut  or  punched-out  through  the 
tissues,  as  are  certain  channels  of  morbid  origin  found  occasionally  at 
these  sites.  The  appearance  at  once  suggests  to  the  mind  the  forcible 
extravasation  at  numerous  points  of  a  coagulable  material  which  has 
driven  the  textural  elements  asunder  before  it ;  a  suggestion  further 
favoured  by  the  almost  invariable  presence  of  a  blood-vessel  (often 
of  considerable  magnitude)  running  in  close  proximity  to,  or  even 
appearing  to  lose  itself  in,  the  morbid  focus.  The  morbid  material  is 
seen  to  consist  of  a  congeries  of  oval  or  spherical  segments  of  delicate 
and  indistinct  outline,  the  sole  indication  of  which  is  often  the  gentle 
curve  of  a  connective  fibre  passing  over  it  (^Pl.  vi..  Jig.  2).  Usually 
pellucid,  it  may  be  found  slightly  opalescent,  whilst  overlying  and 
passing  between  its  segments  is  an  extremely  fine  plexus  of  fibrils. 
Some  of  the  fibres  branch  dichotomously,  and  have  the  appearance 
of   veritable    elastic    fibres ;    others    arise    from    delicate    spider-cells, 


MILIARY    SCLEROSIS.  461 

■which  are  numerously  scattered  around  the  confines  of  the  diseased 
patch  {PL  vi.,  fig.  3).  Around  their  lobulated  contour  we  find  a 
condensation  of  tissue,  the  nerve-fibres  atrophied  or  absent,  and 
the  sclerous  tissue  and  blood-vessels  closely  packed  and  curving 
round  the  mass.  But  the  more  important  point  to  note  is  that 
all  the  medullated  fibres,  in  a  line  with  the  diseased  tract,  are 
in  a  condition  of  advanced  disease,  and  end  directly  in  this  morbid 
focus ;  extreme  varicosity  with  segmentation  of  the  medullated  sheath 
is  apparent.  These  medullated  fibres,  as  they  approach  the  diseased 
focus,  are,  in  many  cases,  seen  to  be  regularly  moniliform,  segmenta- 
tion of  the  white  matter  of  Schwann  having  proceeded  so  far  that 
spherical  masses  of  medulla  are  strung  upon  the  axis-cylinder  like 
beads  upon  a  string ;  at  times  the  retraction  of  the  segmented 
portion  is  not  so  great,  and  an  irregularly  varicose  aspect  ensues ; 
whilst,  in  other  cases,  large  pyriform  masses  of  medulla  are  seen,  the 
axis-cylinder  extending  like  a  stalk  from  its  narrow  end  {PI.  vii.). 
Beside  these  varicose  fibres  lie  naked  axis-cylinders  wholly  devoid  of 
an  investing  medulla,  and  swollen  beyond  their  natural  dimensions. 

The  spherical  masses  of  medulla  exhibit  a  series  of  progressive 
changes  towards  disintegration.  The  early  stage  is  represented  by 
the  simple  spheroid  or  pear-shaped  mass,  perfectly  clear  and  trans- 
lucent, with,  perhaps,  a  faint  indication  of  the  axis-cylinder  running 
through  its  centre  or  displaced  laterally.  The  next  stage  presents  a 
slightly-frosted  clouding  of  its  interior,  followed  later  on  by  the  forma- 
tion of  numerous  extremely  minute  granules  within.  In  the  third 
stage  the  spheroid  becomes  not  only  full  of  these  granules  (apparently 
fatty  in  nature),  but  its  whole  mass  takes  up  a  faint  staining  of 
aniline  or  hsematoxylin  dye,  whereby  it  is  distinctly  contrasted 
with  the  clear  spheroids  of  an  earlier  stage  which  remain  unstained 
{PI.  vii.). 

In  the  immediate  neighbourhood  of  these  segmented  medullated 
fibres  careful  examination  reveals  a  vast  number  of  spindle-cells ;  so 
delicately  pellucid  are  these  bodies,  and  so  faintly  do  they  take  up  the 
staining  reagent,  that  they  are  readily  mistaken  for  free  nuclei,  since 
their  nucleus  is  always  deeply  stained,  and  this  error  is  not  unfrequently 
committed.  At  the  height  of  the  morbid  activity,  however,  the  nature 
of  these  elements  undergoes  a  remarkable  change ;  they  then  stain 
well,  even  to  their  ultimate  ramifications,  and  they  apply  themselves 
so  well  to  the  task  of  removing  disintegrative  material  arising  from  the 
nerve-tissue  that  their  interior  soon  becomes  filled  with  the  minute 
granules  which  we  have  referred  to  as  clouding  the  medullary 
spheroids  {PL  vi.,  fig.  2,  PL  vii.).  These  lymph- connective  elements 
thrive   abundantly  at   the    expense  of  the  nerve-tissue   and   enlarge 


462  THK    MORBID    BRAIN    IN    INSANITY. 

greatly  in  bulk,  whilst  their  extensive  ramifications  pervade  its 
structure  in  all  directions.  Along  the  couise  of  such  degenerating 
medullary  fibres  the  bead-like  segmentation  often  produces  a  clo.se 
resemblance  to  a  series  of  large  cells,  a  resemblance  which  becomes 
most  striking  by  the  occurrence  of  what  looks  like  a  fair-sized 
nucleus  occupying  the  centre  of  each  sphere;  undoubtedly  they  have 
been  frequently  described  as  cells,  an  error  not  to  be  wondered  at 
since  few  reagents  display  well  their  real  nature ;  carmine  and  hsema- 
toxylin  help  to  falsify  the  appearance,  but  aniline  blue-black  with 
bright  illumination  seems  best  adapted  for  exhibiting  their  real 
constitution.  With  other  dyes  they  might  readily  pass  for  nuclei 
arranged  along  the  nerve-fibre  at  each  of  its  moniliform  segments, 
did  we  not  know  that  the  medullated  fibres  of  the  centric  nervous 
system  (unlike  the  peripheral  nerves)  are  devoid  both  of  nuclei 
and  of  Schwann's  sheath,  being,  in  fact,  not  made  up  of  inter- 
annular  segments.  Properly -prepared  sections,  however,  show  that 
this  apparent  nucleus  does  not  occupy  the  interior,  but  lies  upon  the 
exterior  of  the  sphere,  and  is  in  reality  the  nucleus  of  a  young  spideP- 
Cell,  surrounded  by  a  little  granular  protoplasm  from  which  delicate 
branches  radiate  and  clasp  the  spherule  of  myelin  (PL  vii.).  Being 
closely  appressed  to  the  spheroid,  it  looks  like  a  protruding  nucleus;  and 
the  regularity  with  which  a  whole  series  of  such  moniliform  enlargements 
in  a  line  with  each  other  show  these  aggressive  cells,  would  appear  to 
indicate  a  remarkable  morbid  affinity.  It  is  also  to  be  noted  that  where 
these  nucleated  spider-cells  apply  themselves,  the  medullated  spheres 
have  all  undergone  a  granular  Change  and  admit  of  staining"; 
where  the  myelin-droplets  remain  clear,  homogeneous,  and  unstained, 
these  nucleated  cells  do  not  present  themselves.  On  the  other  hand, 
these  scavenger-cells  appear  abundantly  in  the  dense  sclerosic  tissue 
immediately  surrounding  a  miliary  patch. 

The  degenerative  change  which  we  have  thus  followed  in  the  medul- 
lated  fibres  of  the  spinal  cord  is  recognisable  as  an  all-important  feature 
in  the  white  medullated  strands  of  the  cerebral  convolutions  in  chronic 
alcoholism,  and  especially  in  senile  atrophy  of  the  brain ;  the  same 
activity  of  the  lymph-connective  system  prevails  in  these  cases,  and  (as 
we  shall  see  when  treating  of  these  affections)  spider-cells  accumulate 
around  the  disintegrating  nerve-fibre.  In  the  cortex  of  the  brain  these 
spider-cells  are  often  found  (during  the  disintegrative  stages  of  disease) 
to  contain  small  masses  of  deeper  stained  material  apparently  derived 
from  the  neighbouring  nerve-cells  (PL  xv.,  Ji(/.  3).  Eventually  the 
fibrillation  so  resulting  entirely  replaces  the  nervous  tissue,  so  that 
deep-stained  tracts  consisting  of  sclerous  tissue  only  are  seen  here  and 
there  at  the  more  advanced  sites  of  disease. 


SccLvengtr  cells 


,    Scgijvenger  cecls 
ff'      y  filled-  vn.ih  aranv.1 


ijchre  i~ 
-  tOLiion.. 


Degeneration    of  Nerve -fi'bres    of   lateral 
so-called  "Colic 
of  these  tracts 


f  S-piiLsl  cord  vci  so-called  "Colloid  de^en 


MILIARY    SCLKROSIS.  463 

Thus,  in  the  immediate  neighbourhood  of  these  patches  of  miliary 
sclerosis,  we  find  the  nervous  tissue  in  a  state  of  papenchymatous 
deg'eneration,  which,  resulting  in  destruction  and  atrophy  of  the 
essential  elements,  becomes  the  site  of  a  g'enuine  SClePOSiS.  What 
relationship  exists  between  the  unstained  patches  of  miliary  sclerosis 
and  the  condition  of  parenchymatous  degeneration  around  ? 

We  have  ali-eady  referred  to  the  invariable  presence  of  a  fair-sized 
blood-vessel  lying  in  direct  contact  with  these  patches  of  miliary  de 
generation.  If  these  be  closely  examined  we  find  reason  for  believing 
that  the  coats  of  the  vessel  are  involved  by  extension  in  the  morbid 
process,  the  coats  are  unduly  thickened,  the  perivascular  nuclei  have 
undergone  great  proliferation,  the  vessels  are  much  contorted,  and  very 
frequently  occluded.  We  would  suggest  that  the  patch  of  miliary 
degeneration  may  be  directly  due  to  this  implication  of  a  neighbouring 
blood-vessel,  by  the  exudation  from  the  vessel  inducing  such  swelling 
of  the  myelin  as  to  rupture  the  delicate  investing  albuminous  sheath, 
or  possibly  by  a  direct  action  upon  the  latter.  The  patch  undoubtedly 
consists  of  altered  myelin  exuded  in  droplets  from  the  medullated 
tubes  and  coalescing  more  or  less  completely — the  axis-cylinders  forced 
aside  with  the  neighbouring  tissues,  or  undergoing  complete  solution  of 
continuity.  In  a  large  proportion  there  can  be  very  little  doubt  that 
disruption  of  the  axis-cylinder  occurs,  judging  from  the  appearances 
presented  by  the  section  of  the  miliary  spot.  The  skeleton  framework 
of  the  structure,  however,  still  remains  in  the  form  of  a  delicate  plexus 
of  elastic  fibrils  beautifully  dissected-out  by  the  process,  and  brou<^ht 
into  relief  upon  the  colourless  spherules  of  myelin ;  with  these  there 
becomes  blended  ultimately  a  fine  stroma  of  fibres  arising  from  the 
spider-cells  around.  The  latter  condition  occasionally  proceeds  to  an 
excessive  extent  in  similarly  degenerative  foci  in  the  cerebrum  and 
cerebellum,  when  we  meet  with  isolated  tufts  of  delicate  interlacin<y 
fibres  forming  dense  meshworks  (beautifully  revealed  by  aniline  dyes 
in  the  fresh  brain),  which  are  devoid  of  nervous  structure  and  of  all 
cellular  elements  alike.  In  other  instances  the  small  nodule  falls  out 
during  preparation,  or  (as  Dr.  Batty  Tuke  observes)  may  be  picked-out 
with  the  point  of  a  knife  from  the  hardened  brain.  The  naked-eye 
appearance  of  these  formations,  as  they  present  themselves  in  situ  in  a 
segment  of  the  cord,  is  that  of  just  perceptible  points  perfectly  white 
and  opaque,  and  thus  contrasted  strongly  with  the  deep  chrome  tint  of 
the  surrounding  tissue.  Removed  by  a  pin-point  to  a  glass  slide,  they 
are  found  to  resist  considerably  the  pressure  applied  to  the  cover  »lass, 
but  upon  the  addition  of  a  drop  of  bichromate  of  potash  solution  firm 
pressure  resolves  them  into  tolerably  large  spherical  bodies.  Osmic 
acid  does  not  darken  these  morbid  formations,  but  this  fact  mi^^ht  be 


464  THE    MORBID    BRAIN    IN    INSANITY. 

anticipated  from  the  change  induced  by  the  chrome  salts.  The  effect 
of  nitric  acid  and  other  reagents  has  been  studied  by  Dr.  Rutherford ; 
the  former  renders  the  mass  transparent,  and  subsequently  resolves  it 
into  a  number  of  colourless  bodies  about  the  size  of  a  blood-corpuscle, 
apparently  formed  by  the  coalescence  of  droplets  occasioned  by  the  acid 
solution  of  the  mass.  By  pressure  on  the  cover  glass  these  bodies  be- 
come elongated  and,  eventually,  removed  entirely,  leaving  a  delicate 
fibrous  stroma  of  connective  in  their  place.  Strong  sulphuric  acid  acts 
similarly.  It  will  be  seen  from  the  above  remarks  that  we  regard 
these  multiple  lesions  not  as  a  primary  sclerosic  change,  but  as  acci- 
dents occurring  in  the  course  of  a  subacute  inflammatory  or 
deg'enerative  Chang^e  in  the  medullated  nerve  tracts ;  and  that 
when  (during  the  progress  of  a  parenchymatous  inflammation  of  these 
structures)  the  tunics  of  an  adjacent  blood-vessel  become  involved, 
there  we  get  the  rupture  of  these  globose  masses  in  the  nerve-tubuli 
and  their  coalescence  in  the  patches  of  miliary  deposit,  which  are  most 
probably  altered  in  constitution  by  the  inflammatory  efli"usion  from  the 
blood-vessel.  That  it  is  not  an  essential  feature  in  the  history  of  such 
inflammatory  activity  is  sufficiently  evidenced  by  its  frequent  absence; 
yet,  it  is  our  opinion  that  in  the  nervous  tissues  of  the  insane  its  occur- 
rence is  more  frequent  than  is  usually  supposed. 

It  is  well  known  how  difficult  of  demonstration  are  the  several 
deo'enerative  and  chronic  inflammatory  changes  which  occur  in  the 
medullated  tracts  of  the  brain  in  insanity,  and  how  liable  such  changes 
are  to  be  overlooked.  The  presence  of  such  miliary  spots,  therefore, 
is  one  of  very  great  interest  and  importance,  as  calling  attention  to  the 
morbid  state  of  the  nerve-fibres  in  the  immediate  neighbourhood.* 

*  The  following  letter  from  Dr.  Batty  Tuke,  inserted  here  by  his  wish,  will  serve 

to  indicate  how  far  he  retains  his  former  opinion  with  respect  to  the  morbid  change 

in  question  : — 

"Edinburgh,  May  24iJL,  1889. 

"Dear  Dr.  Bevan  Lewis, 

"  After  seeing  your  sections  and  comparing  them  with  my  own,  t  am 
convinced  that  most  of  the  lesions  described  by  Prof.  Rutherford  and  myself  many 
years  ago  are  due,  as  you  suggest,  to  myelitic  changes.  These  clianges  are,  for  the 
most  part,  the  result  of  the  increase  of  the  white  substance  of  Schwann.  I  am 
gratified  to  find  that  you  agree  with  what  we  said  as  to  the  material  importance 
of  these  appearances  in  the  morbid  anatomy  of  chronic  insanity.  I  am  not  pre- 
pared to  give  up  the  theory  that  certain  of  the  changes  we  described  may  not  be 
produced  in  other  ways,  and  may  not  be  due  to  degeneration  of  other  brain 
elements.     But,  as  I  have  already  said,  I  am  with  you  in  the  main. 

"  After  your  remarks  on  the  subject  it  is  unnecessary  for  me  to  enter  upon  any 
argument  to  prove  that  miliary  sclerosis  is  not  the  result  of  the  action  of  hardening 
agents.  Such  position  is  rendered  quite  untenable  by  the  simple  fact  that  the 
lesion  is  often  demonstrable  in  fresh  frozen  specimens. — I  am,  yours  sincerely, 

"John  Batty  Turk." 


coi.Loui  i>i':(;i;Ni';iiATioN.  465 

Colloid  Deg*enePation. — A  very  frequent  lesion  found  in  the  brain 
of  the  insane;  is  that  which  has  been  termed  "  colloid  degeneration,"  a 
term  applied  to  the  presence  of  minute  round  or  oval  bodies,  from 
6  //,  to  12  /i  in  diameter,  which  pervade  the  nervous  structures  oc- 
casionally in  extraordinary  numbers.  The  frequency  of  its  occurrence 
in  the  brain  and  spinal  system  of  the  insane,  its  undoubtedly  morbid 
origin,  and  the  essential  nature  of  the  lesion  indicate  it  as  one  of 
the  most  important  conditions  for  our  consideration  in  the  morbid 
histology  of  insanity. 

Some  nine  years  ago  we  described  as  a  frequent  appearance  in  the 
nervous  tissues  of  the  insane  certain  peculiar  morbid  products,  which, 
although  tmdoubtedly  derived  from  the  medullated  nerve-fibre,  bore  a 
striking  resemblance  to  the  so-called  colloid  bodies,*  and  we  ventured 
to  suggest  their  actual  identity,  but  withheld  any  dogmatic  statement 
of  the  case,  until  further  observation  had  assured  us  that  the  usually 
I'eceived  opinion  of  their  constitution  was  fallacious.  Repeated  ob- 
servations since  this  date  fully  confirm  our  former  suggestion  that 
these  morbid  products  have  been  too  hastily  relegated  to  the  chapter 
of  diseases  of  the  connective  framework  or  neuroglia ;  and  assure  us, 
moreover,  that  the  morbid  bodies  then  described  by  us  were  identical 
in  their  nature  with  the  '•'  colloid  "  body.  The  name  is  unfortunate, 
since  it  assumes  a  colloid  transformation  of  a  connective  cell  similar  to 
what  occurs  in  the  typical  colloidal  transformation  of  the  epithelia  of 
the  thyroid  gland,  or  the  same  change  in  the  elements  of  new  growths, 
and  we  feel  convinced  that  in  this  cellular  origin  of  the  change  the 
view  is  inaccurate.  In  size  these  bodies  vary  very  considerably,  from 
6  to  12  ^  in  diameter,  up  to  40  im — the  former  being  the  usual 
dimensions  of  those  found  in  the  cerebral  convolutions,  the  latter 
those  of  the  regions  of  large  medullated  fibres,  such  as  the  medulla 
oblongata.  Dr.  Batty  Tuke  gives  their  diameter  at  o-yVo'  *°  Tm)~s  °^ 
an  inch,  but  this  clearly  applies  to  the  minute  colloid  bodies  of  the 
cerebral  gyri ;  he  also  notes  their  variability  in  size,  quoting  certain 
experiments  of  his  own  and  Dr.  M'Kendrick  on  the  brain  of  pigeons, 
in  which  colloid  bodies  were  discovered  of  very  minute  size  {-^xru  i^ch). 

As  we  have  elsewhere  stated,  they  vary  in  direct  relation  to  the 
varying  diameter  of  the  medullated  nerve-tracts  in  which  they  are 
found.  In  form  these  morbid  bodies  are  spherical,  ovoid,  or  pyriform, 
their  marginal  contour  in  later  stages  becoming  often  crenulate. 
They  are  perfectly  homogeneous  in  structure,  devoid  of  concentric 
markings,  colourless  and  pellucid,  they  may  become  slightly  tinged  by 
hsematoxylin,  but  are  wholly  unafi"ected  by  carmine  or  aniline  dyes, 

*  "Lesions  of  the  nervous  tissues  in  the  brain  of  the  insane,"  Brain,  Oct., 
1879,  p.  364. 

30 


466  TIIK    MORBID    HUAIX    IN    INSANITY. 

and  thoy  exliibit  no  reaction  with  the  iodine  and  sulphuric  acid 
test. 

A  case  of  bulbar  paralysis  occurring  at  the  West  Eiding  Asylum 
showed  the  lower  half  of  the  medulla  to  be  the  site  of  this  lesion  to 
such  an  extent,  that  its  sections  under  a  low  power  appeared  as  if 
besprinkled  by  thousands  of  minute  droplets,  and  yet  to  the  naked 
eye  no  abnormal  appearance  presented  itself,  and  the  section,  although 
pale,  was  uniformly  and  faii-ly-well  stained.  A  glance  at  the  accom- 
panying sketch  [PI.  viii.)  will  reveal  the  microscopic  dimensions  of 
these  bodies  and  their  wide-spread  implications.  Yet  it  will  be 
eijually  obvious  how  absolutely  the  limits  of  the  grey  matter  of  the 
medulla  is  respected.  Thus,  in  the  olivary  bodies  we  observe  these 
morbid  formations  wholly  confined  to  its  medullated  core,  and  nowhere 
implicating  its  plicated  grey  su.bstance,  except  where  the  latter  is  traversed 
by  medullated  fibres ;  and  the  same  remark  applies  to  the  grey  matter 
of  the  floor  of  the  fourth  ventricle,  and  nuclei  of  the  cranial  nerves. 

The  following  is  a  resume  of  the  clinical  features  and  pathological 
appearances  in  this  case  : — 

T.  W, ,  aged  thirty,  married.  He  is  a  stone-mason,  and  was  stated  to  have  been 
insane  for  five  months  upon  his  admission.  Two  years  previous  to  this  date  he 
was  stated  to  have  had  a  paralytic  stroke.  Five  weeks  prior  to  admission 
he  again  had  a  paralytic  seizure  (right  hemiplegia),  was  deprived  of  speech, 
and  became  depressed  and  suicidal ;  great  and  increasing  difiiculty  in  degluti- 
tion had  been  noted  since  this  second  paral3'tic  seizure.  On  admission  to  the 
asylum  he  was  completely  speechless,  could  only  utter  inarticulate  sounds,  or  try 
to  explain  himself  by  gesture  and  pantomime.  He  appreciated  all  that  was  said  to 
him,  but  showed  considerable  amnesia.  When  asked  to  write  down  his  name  he 
took  up  the  pencil  with  his  left  hand  first,  and  then,  transferring  it  to  his  right, 
hesitated  for  some  time  as  if  tryuig  to  recall  something,  and  then  threw  it  down  in 
despair.  He  expressed  numbers  by  tapping  successively  with  his  finger  on  the 
table.     He  had  been  a  steady  man,  of  temperate  habits. 

Circulatorj^  respiratory,  and  genito-uriuary  systems  appeared  normal. 

His  gait  was  somewhat  unsteadj',  but  there  was  no  inclination  to  one  side;  the 
grip  of  the  right  hand  is  much  diminished,  and  he  uses  his  left  hand  in  lieu  of  the 
right ;  no  muscular  wasting  is  apparent.  The  extremities  are  extremely  cold,  and 
both  the  feet  and  hands,  as  well  as  nose  and  cheeks,  are  livid  ;  a  similar  patchy 
lividity  is  seen  over  the  whole  body.  He  fails  to  whistle  or  spit ;  cannot  close 
his  mouth,  but  opens  it  widely ;  saliva  constantly  dribbles  from  the  mouth  ;  he 
swallows  fluid  food  only,  and  that  with  the  greatest  difiiculty,  throwing  his  head 
far  back  and  accomplishing  the  act  only  after  a  prolonged  effort,  and  then  with 
much  spluttering.  The  tongue  appears  completely  paralysed,  lies  helplessly  on 
the  floor  of  the  mouth,  and  cannot  be  protruded  or  laterally  displaced. 

Common  sensibility  and  reflex  activity  appear  normal  and  equal  on  both  sides  ; 
perception  of  temperature  and  electric  sensibility  normal ;  all  the  affected  muscles 
react  energetically  with  feeble  faradaic  stimulation;  all  special  senses  appear  normal. 
The  pupils  are  dilated,  the  right  pupil  being  the  larger  and  more  sluggish.  For 
five  years  he  remained  a  most  anxious  case  for  feeding,  beiug  in  constant  danger  of 


Accessory  Uiivary  bodies 
P  a  r  al  V  s  i  s  she"wiTi^ 


BULBAR    PARALYSIS — SIONIFICANCK    OF    COLLOID    CHANGE.  467 

choking.     He  had  no  further  paralytic  seizure,  and  died  eventually  of  pulmonary 
gangrene. 

Summari)  of  Au/ojjsi/. — Bones  of  skull  thickened  and  very  dense  ;  no  adhesion  of 
dura  mater ;  the  pia-arachnoid  is  opaque  at  the  vertex,  thickened,  tough,  and 
buoyed  up  by  much  serous  fluid.  In  both  hemispheres  there  is  considerable  atrophy 
of  the  convolutions,  and  where  this  wasting  is  extreme  the  cortex,  after  removal 
of  the  membranes,  presents  well-marked  cauliflower  [tuckering  of  the  surface.  The 
whole  brain  weighed  but  990  grammes.  The  thickened  membranes  stripped  with 
ease  from  all  parts  of  the  surface,  except  at  certain  sites  where  softening  of  the 
cortex  had  occurred.  The  softened  patches  were  disposed  with  a  certain  degree  of 
symmetry  on  both  sides,  thus  : — 

Right  Hemisphere.  Left  Hemisphere. 

Slight  along  lower  third  of  ascending         Lower  half  of  ascending  frontal. 

frontal.  Three  upper  annectants  and  bound- 

Second  annectant  gyrus  and  cortex  of  aries  of  parieto-occipital  sulcus. 

interparietal  sulcus. 
Middle  of  third  frontal  gyrus. 

The  patch  of  softening  is  generally  of  a  greyish  colour,  translucent,  and  gelatini- 
form,  its  centre  of  bright  yellow  hue  surrounded  by  a  greyish  translucent  zone  ; 
it  is  pulpy  and  torn  upon  removal  of  the  superjacent  membranes. 

The  cauliflower  puckering  characterising  the  sites  of  most  extreme  wasting  were 
disposed  in  the  right  hemisphere  along  the  convolution  bounding  the  longitudinal 
fissure,  the  middle  of  the  second  frontal  and  the  angular  gyrus  ;  in  the  left  hemi- 
sphere it  involved  the  postero-parietal,  the  middle  of  the  second  frontal,  and  a 
portion  of  the  second  temporo-sphenoidal  convolution. 

Respecting  the  other  organs  of  the  body,  the  only  point  essential  to  note  here 
(beyond  the  gangrenous  condition  of  the  lung)  was  the  absence  of  any  cardiac 
disease,  and  the  presence  of  granular  and  wasted  kidneys,  somewhat  extreme  in 
both  instances. 

In  the  brain,  also,  we  find  these  bodies  encroach  upon  the  grey 
matter  only  exceptionally,  and  then  invariably  along  the  direction  taken 
by  the  large  medullated  tracts  (the  tang'ential  fibres  of  the  periphePal 
zone  more  especially),  and  more  rarely  the  intraCOrtical  arcifOPm 
fibres  {PI-  ix.,  figs.  1,  2).  We  have  already  alluded  to  the  same  limi- 
tation as  regulating  the  distribution  of  the  "  miliary"  patches. 

No  theory  of  the  connective  origin  of  these  morbid  formations  could 
account  for  this  peculiar  restriction.  Reverting  to  the  case  of  bulbar 
paralysis  [PI.  viii.),  we  find,  these  morbid  products  especially  large  and 
suitable  for  study  along  the  fibres  of  the  median  raphe,  the  emergent 
root-fibres  of  the  hypoglossal,  and  the  arciform  fibres  near  the  raphe 
posteriorly.  In  these  positions  they  lie  either  superimposed  to  the 
medullated  fasciculi,  or  are  crossed  superficially  by  others ;  but,  when- 
ever their  conformation  assumes  an  elongate  outline,  their  long 
diameter  takes  the  direction  of  the  medullated  fasciculus  lying 
parallel  to  the  fibres.     In   many   instances  they   are   distinctly   seen 


468  THE    MORBID    BKAIN    IN'    INSANITY. 

to  be  an  oval  swelling  aloug  tlie  course  of  the  medullated  fibre,  and 
the  axis-cylinder  can  be  traced  through  the  centre  of  the  swelling; 
in  other  instances  a  pyriforni  body  presents  itself,  the  narrow  end  of 
which  is  directly  continuous  with  a  swollen  and  deeply-stained  axis- 
cylinder;  or,  again,  a  subglobose  body,  from  the  two  poles  of  which 
the  medullated  axis  is  continued  (although  not  traceable)  within  its 
structui-e.  Some  of  the  largest  examples  of  the  elliptic  form  attain  the 
dimensions  of  55  /«.  by  37  /a. 

The  presence  of  a  nucleus  within  these  bodies  has  been  said  to  occur, 
giving,  of  course,  much  colour  to  the  account  of  their  cellular  origin  ; 
with  respect  to  this,  we  stated  in  the  article  already  referred  to,  that 
such  bodies  were  always  extraneous.  "  Occasionally  a  nucleus  appeared 
on  the  surface  or  border  of  these  bodies,  but  it  could  always  be  regarded 
as  extraneous  to  the  morbid  formation  and  accidentally  superimposed."* 
Our  methods  of  preparation  now  enable  us  to  considerably  extend  such 
a  statement ;  not  only  are  they  in  all  cases  extraneous  to  the  morbid 
swelling,  but  they  are  not  free  nuclei ;  they  are  really  the  nuclei  of 
spider-cells  (which  are  found  when  carefully  looked  for)  attached  to 
most  of  these  so-called  colloid  bodies  {PI.  vii.).  So  far  from  being,  as 
we  supposed,  accidentally  superimposed,  they  are  important  elements 
in  the  morbid  role,  their  significance  being  identical  with  what  has 
already  been  delineated  in  our  description  of  '•'  miliary  sclerosis." 

The  "  colloid  "  body  is,  in  its  early  stage,  perfectly  translucent  and 
so  minute  that  (unlike  the  miliary  patch)  it  is  not  evident  to  the 
naked  eye  under  reflected  light  (P?.  x.  B.);  it  is  likewise  attached,  form- 
ing an  integral  part  of  the  medullated  fibre,  and,  hence,  not  removable 
like  the  miliary  deposit;  it  is,  also,  a  single,  homogeneous  body  showing 
(of  course)  no  stroma  of  fibrils  through  its  structure ;  but  these  difier- 
ences  do  not,  we  observe,  indicate  a  distinct  pathogenesis.  Given 
certain  conditions  at  a  later  stage,  and  the  colloid  bodies  become 
opalescent  or  granular,  swell  to  greater  proportions,  burst  their  albu- 
minous sheath  and  coalesce  as  free  miliary  products,  appear  multi- 
locular  and  have  their  structure  permeated  by  the  ramifying  processes 
of  scavenger  spider-cells  {PI.  vi..  Jigs.  2,  3). 

The  history  is  the  same  for  all  parts  of  the  cerebro-spinal  axis  con- 
taining medullated  fibres ;  but,  as  before  stated,  the  transition  stages 
are  best  studied  where  the  larger  medullated  fibres  exist  in  the  region 
of  the  pons,  medulla,  and  lateral  columns  of  the  cord.  That  this 
transition  from  the  "  colloid  "  to  the  "  miliary"  formations  had  occurred 
in  the  case  quoted  years  since  by  Kesteven,  is  to  our  mind  conclusive. 
In  his  case  the  section  of  medulla  of  a  patient,  of  whom  the  clinical 
history  was  unfortunately  wanting,  appeared  under  a  low  power  to  be 

*  Loc.  cit.,  p.  366. 


SIGNIFICANCE   OF    MILIARY    AND    COLLOID    CIIANGK.  469 

full  of  minute  cavities  or  perforations,  which,  when  examined  by 
higher  powers,  were  found,  in  many  instances,  filled  with  a  fine 
granular  substance,  similar  to  what  we  have  already  described  as 
found  in  "  miliary  "  patches.  This  drawing  of  the  morbid  groupings 
in  the  medulla  reproduces  the  appearance  met  with  in  the  case  of 
bulbar  paralysis  already  alluded  to  {PI.  viii.),  with  this  exception, 
that  in  the  latter  case  the  product  of  morbid  activity  was  far  more 
profusely  scattered,  and  the  individual  bodies,  of  course,  very  minute 
(not  having  coalesced  into  miliary  patches).  Mr.  Kesteven  observes 
in  reference  to  his  case  : — 

"These  cavities  are  irregular,  scattered,  without  evidence  of  order,  throughout 
the  medulla  oblongata  referred  to.  They  cannot  be  said  to  predominate  specially 
in  any  one  of  the  elements  of  the  organ;  but  if  they  prevail  at  all  in  any  part, 
it  may  perhaps  be  said  that  they  are  rather  more  numerous  posteriorly  than 
anteriorly.  In  one  section,  about  the  level  of  the  calamus  scriptorius,  I  counted 
several  hundreds  of  these  cavities."  Again  he  adds :— "  The  surrounding  textures 
appear  to  be  perfectly  healthy,  with  entire  absence  of  any  inflammatory  action ; 
neither  is  there  sign  of  disease  of  the  blood-vessels  in  the  surrounding  tissue.  The 
morbid  change  is  restricted  to  these  detached  points,  and  it  is  wholly  a  matter  of 
conjecture  whether  it  commenced  in  the  capillaries,  or  in  nerve-tubes  or  cells."* 

Whenever  this  lesion  appears  in  the  spinal  axis,  it  will  be  found 
advisable  to  study  its  nature  in  longitudinal  sections  and  by  the  aid  of 
aniline  dyes. 

To  summarise  our  results,  we  regard  both  the  "  miliary "  and 
"  colloid  "  change  as  representing  stages  in  the  progress  of  a  chronic 
degenerative  affection  of  the  medullated  fibres  of  the  centric  nervous 
system ;  an  affection  which  is  of  most  frequent  occurrence  in  the  brain 
of  the  insane,  and  one  of  most  vital  import.  A  difference  of  opinion 
may  exist  regarding  the  special  nature  of  the  affection,  whether  it 
should  be  taken  to  indicate  a  simple  degenerative  change  or  one  of 
chronic  inflammatory  irritation  ;  and,  in  fact,  the  same  question  may 
be  asked  concerning  the  changes  resulting  from  section  of  a  peripheral 
nerve.  In  the  one  case,  as  in  the  other,  the  real  origin  of  the  affection 
is  in  the  severance  of  the  fibre  from  its  trophic  cell.  It  is  in  the 
diseased  state  of  the  cortical  nerve-cells  that  we  must  seek,  in  most  of 
our  cases  of  insanity,  for  an  explanation  of  this  degeneration  of  the 
nerve-fibres  ;  of  course,  any  lesion  causing  severance  betwixt  the  two, 
at  any  site  along  the  fibre,  will  act  in  like  manner,  but  the  central 
disease  in  the  cortical  cell  is  usually  the  primary  fact  presented  to  us. 
The  segmentation  of  myelin,  occurring  in  this  chronic  affection, 
difiers  in  some  important  particulars  from  what  we  see  taking  place 

*  See  original  article,  "Notes  of  a  Peculiar  Form  of  '  Granular  Degeneration ' 
observed  in  a  Medulla  Oblongata."  By  W.  B.  Kesteven.  Brii.  and  For.  Med. 
Chit:  Rev.,  April,  lS6t1. 


470  TUE    MORBID    BRAIN    IN    INSANITY. 

ill  degeneration  from  section  of  peripheral  nerves.  Thf  latter  is 
apparently  a  more  active  process,  and  is  the  result  of  the  direct  morbid 
activity  of  the  cellular  constituents  of  the  nerve-fibre  ;  in  its  enlarged 
and  dividing  nucleus,  and  increased  development  of  protoplasm,  we 
recognise  (as  long  since  taught  by  Ranvier)  the  destructive  agencies 
which  bring  about  the  segmentation  and  eventual  destruction  of  the 
axis-cylinder  and  its  medullary  investment.  In  the  more  delicate 
fibres  of  the  brain  and  spinal  cord,  segmentation  of  the  myelin  occurs 
more  spontaneously ;  and  as  the  medulla  separates  into  varicose 
nodules  along  the  length  of  the  fibre,  it  becomes  less  susceptible  to 
staining  by  Pal's  process,  which,  in  the  healthy  fibre,  stains  the 
niedullated  sheath  of  a  deep  purple,  leaving  the  axis-cylinder  untouched. 
It  is  then  often  noticed  that  the  annular  segments,  although  per- 
fectly uncoloured  for  the  greater  part  by  this  process,  yet  have  a  slight 
coloured  fringe  around  both  poles,  the  intervening  medullated  connec- 
tion with  the  adjacent  varicosity  being  normally  stained  and  continuous 
with  this  coloured  fringe.  The  appearance  suggests  an  unchanged  part 
of  the  medulla  or  its  albuminous  sheath  at  this  site ;  possibly  remains 
of  the  ruptured  sheath.  We  must  not  regard  varicosity  of  the  fibres 
as  conclusive  of  a  commencing  degenerative  change  ;  but  when  extreme 
varicosity  of  the  larger  medullated  fibi-es  is  associated  with  their 
tendency  to  take  up  aniline  and  carmine  staining,  when  they  exhibit 
granular  contents  and  clouding,  and  especially  when  apparently  free 
granular  masses  with  proliferating  spider-cells  are  seen,  we  may  be 
quite  confident  that  we  are  dealing  with  a  genuine  degenerative 
change;  finally,  the  presence  of  "colloid"  bodies  or  of  "miliary" 
patches  assures  us  of  the  existence  of  the  same  condition. 

Such  extreme  conditions  of  "  colloid  degeneration  "  (referred  to  by 
Dr.  Batty  Tuke  as  of  occasional  occurrence  in  the  white  substance  of 
the  brain,  in  which  the  section  looks  like  "  a  slice  of  cold  sago- 
pudding  ")  are  undoubtedly  states  of  degenerated  medullary  fibres  from 
disease  of  their  centric  cells. 

How  far  does  this  condition  of  the  medullated  fibre  interfere  with  its 
normal  conductibility  or  excitability'?  The  long  persistence  of  the 
axis-cylinder  probably  permits  a  free  conduction  along  the  fibre  for 
some  time  after  the  latter  is  completely  denuded  of  its  myelin  sheath; 
and  we  must  regard  this  as  still  possible  so  long  as  actual  severance  of 
the  axis  be  not  etfected.  Such  severance  occurs  (as  we  have  seen)  in 
the  accidental  accompaniment  of  "miliary  sclerosis,"  and  then  sudden 
interruption  must  occur  in  the  conductibility  of  the  fibre;  but,  apart 
from  such  an  occurrence  the  process  is  one  of  very  chronic  course,  the 
denudation  of  tlie  axis-cylinder  takes  place  very  gradually,  and  the 
latter  eventually  succumbs  to  the  encroachment  of  the  sclerous  tissue. 


GRANULAR    DEGENERATION    OF    NERVE-CELLS.  471 

Granular  Disintegration  of  Nerve-Cells. — The  whole  cell  be- 
comes swollen,  and  assumes  a  more  spherical  contour ;  the  cell 
protoplasm  loses  its  apparent  homogeneity,  and  is  clouded  and 
obscured  by  the  formation  of  granules  within ;  the  devitalised  proto- 
plasm no  longer  shows  its  affinity  for  the  staining  reagents,  and 
becomes  but  faintly  tinted  by  carmine  or  aniline  dyes ;  the  nucleus 
in  like  manner  resisting  these  reagents.  The  nucleus  often  retires 
before  the  degenerating  mass,  is  thrust  aside,  and  becomes  atrophied, 
shrunken,  angular  or  elongated ;  moreover,  the  physiological  pigment 
of  the  cell  (usually  found  in  a  small  collection  at  its  base)  becomes 
uniformly  diffused,  so  that  the  altered  granular  protoplasm  becomes 
of  a  yellowish  tinge  [PL  xv[.,Jlg.  1).  Meanwhile  the  lateral  processes 
have  become  attenuated,  and  eventually  dwindle  down  and  wholly  dis- 
appear; this  gives  the  cell  a  still  more  globose  aspect.  In  like  manner, 
the  apical  process  disintegrates,  but  the  basal  extension  still  remains,  and 
is  often  notably  swollen  and  prominent;  it  is  seen  in  fresh  specimens  to 
be  lai'gely  denuded  of  its  investing  medulla.  These  degenerate  cells 
are  mostly  indistinct  (from  the  absence  of  active  staining),  and  some 
of  the  larger  cells  of  the  fifth  layer  in  the  motor  cortex  look  like  the 
ghosts  of  their  former  selves.  Many  of  the  smaller  cells  are  found 
simply  represented  as  a  small  heap  of  granules  retaining  more  or  less 
the  outline  of  the  original  cell;  the  whole  of  the  field  around  is  the 
seat  of  much  fatty  granular  matter,  and  especially  accumulated 
around  the  blood-vessels.  In  the  case  of  the  latter  we  find  the 
perivascular  spaces  greatly  enlarged,  the  sheath  enclosing  fatty 
granules  and  deposits  of  hsematine ;  the  vessels  are  usually  athero- 
matous, and  fatty  disintegrating  branched  corpuscles  are  spread  on 
their  exterior.  The  presence  of  much  fatty  matter  is  revealed  by  the 
fact  that  fresh  preparations  treated  for  a  few  seconds  only  bv  osmic 
acid  ('25  per  cent.)  tend  to  become  greatly  obscured  by  a  minute 
granular  deposit  forming  over  the  surface  of  the  section.  The  most 
accurate  description  of  granular  degeneration  is,  we  think,  that  first 
recorded  by  Dr.  H.  C.  Major,  and  certainly  before  his  researches  it 
had  never  been  shown  that  a  primary  senile  atrophy  of  the  brain-cells 
occurred  in  senile  dementia.*  That  observer  also  recorded  similar 
changes  in  the  cortex  of  aged  animals,  reproducing  what  he  found  in 
the  human  subject.  Our  further  researches  into  the  subject  have 
resulted  in  the  following  observations.  The  early  stage  of  granular 
disintegration  of  the  cortical  nerve-cells  is  signalised  by  certain 
remarkable  features  in  the  peripheral-zone  of  the  cortex,  immediately 
beneath  the  pia  mater.  Here  the  medullated  fibres  running  parallel 
to  the  surface  assume  an  extreme  degree  of  varicosity,  and  active 
*  West  Biding  Asylum  Beporttf,  vol.  ii. 


472  THE    MORBID    BRAIN    IN    INSANITY. 

degenerative  changes  ensue.  The  elements  of  the  lymph-connective 
system  (spider-cells)  proliferate  and  crowd  around  these  varicose 
fibres,  which  now  become  moniliform  from  segmentation  of  the 
myelin,  so  that  large  globose  or  oval  bodies  unstained  and  connected 
by  a  narrow  neck  constituted  by  the  stained  axis-cylinder,  are  seen  in 
large  numbers  beneath  the  pia  {PI.  ix.,Jig.  1).  The  bodies  from  being 
perfectly  colourless  and  homogeneous,  become  clouded  and  slightly 
granular,  and  a  dense  proliferation  of  the  spider-cells  insinuates 
itself  between  and  around  these  degenerating  fibres,  their  branches 
forming  a  thick  meshwork  of  fibres  in  this  outer  zone  of  the  cortex. 
As  in  this  stage  the  spider-cells  stain  intensely  with  aniline-black, 
we  get  in  such  specimens  the  contrast  of  numbers  of  colourless  and 
somewhat  lustrous  spheres  upon  a  dark  background  of  felted  fibre 
(Fl.  ix.,  Jig.  1).  This  fibrous  meshwork  strikes  down  into  the  first 
cortical  layer  some  distance  beyond  the  limit  of  the  medullated  tract. 
This — the  early — stage  of  granular  degeneration  is  not  so  often  seen, 
we  much  more  frequently  meet  with  the  next  stage,  as  in  subjects  dying 
from  senile  atrophy.  It  was  this  early  stage  of  granular  degeneration 
in  senile  atrophy  that  we  drew  attention  to  some  twelve  years  ago, 
in  an  article  on  the  lymphatic  system  of  the  brain;*  we  there  sketched 
the  appearances  presented  in  such  a  section,  and  reproduce  the  sketch 
here,  since  it  has  been  assumed  by  some  that  these  features  were 
peculiar  to  general  paralysis  (/7.  xv.,Jlg.  1)  ;  we  would  here  insist  that 
all  cases  of  senile  cerebral  atrophy  exhibit  this  proliferation  of  s])ider- 
cells  in  the  earlier  stage  of  its  evolution.  Not  only  so,  but  we  have 
already  sufficiently  indicated  that  we  may  expect  to  find  similar 
appearances  whenever  these  medullated  fibres  are  degenerating,  what- 
ever be  the  cause. 

We  see,  therefore,  reproduced  in  this  layer  of  the  cortex,  in  the 
fatty  or  granular  degeneration  of  the  nerve-cells,  the  so-called  colloid 
degeneration  already  studied  in  the  medulla  and  elsewhere.  Do  the 
same  sclerotic  results  occur  which  we  have  traced  in  the  latter?  If 
this  layer  of  the  cortex  be  carefully  examined  (fresh  sections)  in  the 
more  advanced  stage  of  this  degenerative  aSection,  we  discover  here 
and  there  a  few  colloid  bodies  remaining ;  but,  in  lieu  of  the  long 
series  of  large  moniliform  fibres,  or  groups  of  large  colloid  bodies,  and 
dense  fibrous  meshwork  ai'ound,  we  find  free  nuclei  undoubtedly 
arising  from  the  spider-cells,  scattered  in  numbers  about,  and  each 
nucleus  forming  a  centre,  around  which  an  abundance  of  highly 
refractile  granules  collect,  which  are  of  fatty  nature  (PI.  xv..  Jig.  2). 
These  clusters  of  fatt}'^  granules  around  the  free  nucleus  represent  the 
disintegration  of  the  spider-cell  itself,  for  we  often  observe  some  of 
*  Proc.  Boy.  Soc,  No.  182,  1877. 


irig/l 
. -1    ^.^  -  v^iieratioTv  of  jl.  tu --Lii.i  .^.-'j, 
3  in  first  layer   of    Cortex  wiih 
Scaven*  e^"    ';    ' '  - 
.0  Alcolmiic  li 


♦-©.v.',-,*    »i^  .,    '.P'i^-s^  i  ^SOt"-.  o?       -^    i 


PIGMENTARY    DEGENERATION    OF    NERVE- CELLS.  473 

these  elements  full  of  glistening  particles,  and  with  their  ramifying 
processes  well  seen  lying  amongst  their  disintegrated  congeners. 

The  blood-vessels  also  at  this  stage  have  their  sheath  laden  with 
fatty  debris  and  refractile  granules,  like  those  surrounding  the  nuclei. 
It  can  be  well  appreciated  how,  under  this  process  of  fatty  liquefaction 
and  removal,  this  layer  of  the  cortex  becomes  rapidly  atrophied ;  the 
shrinking  which  occurs  is  apparent  in  the  figure  {PL  xv.,  Jiffs.  1,  2). 

Pigrnentapy  or  Fuscous  Deg-eneration.— The  deposit  of  pig- 
ment in  the  nerve-cells  of  the  grey  matter  of  the  brain  and  spinal  cord 
is  a  constant  feature  in  healthy  states  of  these  centres.  So  far  from 
being  in  itself  an  indication  of  degeneration,  its  absence  should  at 
once  make  us  suspicious  of  the  integrity  of  the  cell-unit,  whilst  its 
presence  seems  indicative,  up  to  a  certain  point,  of  normal  physio- 
logical activity.  In  some  way,  as  yet  not  clearly  understood,  the 
presence  of  pigment  plays  an  important  rdle  in  the  functional  activity 
of  the  nerve-cell,  and  we  need  only  refer  to  its  abundance  in  the  organs 
of  special  sense  to  emphasise  this  fact.  We  have  seen  in  cases  of 
granular  degeneration,  such  as  occurs  in  senile  atrophy  of  the  brain, 
that  the  earlier  stages  of  decline  in  the  functional  vigour  of  the  nerv^ 
cell  is  associated  with  a  diminution  of  its  natural  pigment.  If  the 
dementia  has  been  ushered  in  by  evidence  of  long-continued  and  great 
excitement,  as  in  attacks  of  senile  mania,  then  we  find  a  notable 
degree  of  pigmentation  of  the  degenerated  cell  far  beyond  what  is  seen 
in  health. 

Epileptic  insanity  and  the  insanity  of  general  paralysis  are  of  all 
forms  of  mental  ailment,  those  most  prone  to  excessive  pigmentation, 
but  all  morbid  states  of  the  nerve-centres  which  are  associated  with 
excessive  and  frequent  engorgements  of  their  vascular  apparatus  lead 
to  the  production  of  this  increase  of  pigment ;  and  thus,  we  find  the 
same  condition  of  the  nerve-cell  in  certain  cerebro-spinal  tracts  in 
severe  chorea  and  even  in  so  acute  an  affection  as  hydrophobia.  To 
class  this  "fuscous"  state  with  granular  degeneration  is  we  think 
misleading ;  the  latter  is  truly  a  degeneration  of  the  cell-protoplasm 
and  may  be  associated,  as  we  have  just  said,  with  increase  or  decrease 
of  the  normal  pigment ;  the  former  is  not  truly  a  degeneration,  but 
may  be  associated  with  an  accompanying  retrograde  change  in  the 
neighbouring  protoplasm,  or,  perhaps,  may  be  its  immedilte  cause. 
The  one  fact  clearly  established  in  the  history  of  the  various  psychoses 
is^  that,  where  excessive  pigmentation  of  nerve-cells  is  found,  it  is  a 
witness  to  a  bygone  functional  hyper-activity. 

The  large  ganglionic  cells  of  the  cortex  which  are  peculiarly  prone 
to  this  excessive  pigmentation  offer  us  the  best  means  for  its  illustra- 
tion  both    in   normal   and    abnormal    states.      In  fresh    preparations 


474  TIIK    MOHIill)    HHAIN    IN     INSANITY. 

examined  straight  from  tin-  i'lH'cziiig-iiiicrotomc,  we  tind  at  one  of  the 
inferior  angles,  or  along  the  basal  arc  of  tlie  cell,  ;i  siiiall  collection  of 
golden  yellow  pigment,  through  which  a  number  of  daik,  amorphous, 
minute  granules  are  scattered  ;  it  appears  to  be  surrounded  on  all  sides 
by  protoplasm,  but  is  quite  distinct  from  the  latter  ;  often  it  assumes  a 
somewhat  crescentic  form  partially  encircling  the  nucleus.  In  degenera- 
ting cells,  such  as  we  have  already  referred  to,  the  changes  observed 
in  the  various  stages  are  as  follows  : — First,  the  whole  cell  becomes 
tumid,  and  losing  its  more  elliptic  outline,  approaches  a  somewhat 
pyriform  or  spheroidal  contour,  the  pigment  being  notably  increased 
in  quantity.  At  the  same  time  the  cell-protoplasm  stains  of  an  intense 
depth  of  colour  with  aniline  blue-black  ;  so  deeply  tinged  does  it 
become  that  unless  subjected  to  the  dye  for  an  unusually  short  period, 
the  whole  of  the  unpigmented  protoplasm  and  its  contained  nucleus 
becomes  obscured  [PI.  xiv.).  "With  this  intensity  of  staining  of  one  por- 
tion, of  the  cell  we  have  the  pigmented  portion  wholly  unaffected  by  the 
aniline  or  carmine  dyes,  and  assuming  a  bright  yellow  or  brownish- 
yellow  tinge,  and  a  rough  granular  aspect.  The  cell  becomes  still  more 
globose  in  aspect,  and  its  numerous  radiating  lateral  offshoots  (at  first 
coarse  and  deeply  stained)  can  be  traced  through  the  pigme7ited  patch  up 
to  the  receding  protoplasm.  The  nucleus  is  deeply  stained  by  the 
tisual  reagents  (PI.  xiv.).  This  appears  to  us  to  be  the  first  stage  of 
functional  hyper-activity,  and  we  find,  as  constant  associates  with 
these  degenerating  cells,  coarse,  dilated  blood-vessels,  together  with 
leucocytes  and  ha^matuidin  crystals  along  the  perivascular  channels. 

The  retraction  of  the  unattected  protoplasm  carries  with  it  the 
nucleus  towards  the  apex  of  the  cell,  or  draws  it  out  eccentrically  and 
to  the  side ;  but  at  times  the  invasion  of  the  pigmentary  change 
appears  at  the  summit  of  the  cell  when  the  nucleus  and  investing 
protoplasm  retreat  towards  the  base.  The  nucleus  itself  may  now 
become  pigmented  in  some  cases,  but  in  all  it  assumes  eventually  a 
more  or  less  irregular  angular  contour,  losing  the  plump,  oval  contour 
seen  in  fresh  and  healthy  sections.  At  this  juncture,  also,  tlie  staining 
of  the  cell  by  aniline  becomes  less  evident,  and,  with  the  encroachment 
of  the  ever-increasing  pigmented  area,  faintly  stained  tracts  or  angles 
of  protoplasm  may  alone  remain.  The  radiating  lateral  processes 
dwindle  down  into  extremely  attenuated  extensions  and  entirely 
disappear,  the  cell  being  devoid  of  all  except  a  basal  and  perhaps  a 
short  apical  stump  ;  in  others,  a  few  bristle-like  projections  from  the 
sides  of  the  cell  still  remain,  so  that  it  has  a  somewdiat  spiny  aspect. 
In  this  stage,  whatever  processes  remain  are  but  ^•ery  faintly  stained  by 
reagents,  or  have  a  granular,  degenerating  aspect,  while  the  pigment 
discoloration    can    often    be    traced    far    down    the    process    from    its 


PIflMENTARV    DEOENEHATION    OF    XEltVK-CELLS.  475 

junction  with  tlie  cell.  The  jjigmentcd  area  appears  to  l^e  separated 
from  the  remaining  protoplasm  of  the  cell  by  an  investing  capsule  of 
more  deeply-stained  material,  so  that  when  the  greater  part  of  the 
cell  is  involved  in  the  change,  the  latter  appears  to  possess  a  very 
definite  investing-wall,  deeply-stained  by  aniline,  with  brownish-yellow, 
granular  pigment  within  {PI.  xiii.).  Such  a  sharply-defined,  indurated 
border  gives  the  cell  the  appearance  which  has  been  described  by 
Meynert  and  Lubimoff"  as  a  "sclerosed  swelling."  At  this  period  the 
nucleus,  besides  presenting  an  irregular  contour,  exhibits  one  or  more 
highly-refractile  spots,  probably  of  fatty  nature  ;  it  remains  always  the 
centre  around  which  any  non-pigmented  and  unaflected  protoplasm 
which  is  left  collects.  Hence  many  cells  in  an  advanced  stage  of 
degeneration  exhibit  an  eccentric  nucleus  surrounded  by  a  narrow 
zone  of  stained  (and  hence  presumably  still  healthy)  protoplasm, 
delicate  extensions  of  which  can  be  traced  as  dark  'fibres  running 
through,  the  investing  pigmented  granular  cell-mass,  the  whole  being 
enclosed  within  an  irregular,  distorted,  dark-stained  sclerous  envelope. 
We  have  also  often  observed  a  sharply-defined  cincture  separating  the 
healthier  from  the  degenerate  portion  of  the  cell ;  and  it  may  always 
be  noted  that  the  processes  which  arise  from  the  pigmented  area  are 
more  degenerated  than  those  issuing  from  the  healthier  stained 
segment.  The  individual  granules  seen  in  the  pigmented  mass  are 
from  1  /A  to  2  //.  in  diameter. 

The  last  stage  is  that  of  general  shrinking  of  the  cell,  which  is, 
however,  preceded  by  a  partial  resolution  of  the  bright  yellow  or 
dusky  pigmented  granules  into  many  highly-refractile  globules,  more 
obviously  fatty  in  nature;  whilst  this  admixture  diminishes  the 
fuscous  aspect  of  the  cell  {PI.  xvi..  Jig.  I;  PI.  xviii.).  In  many,  a  still 
more  complete  transformation  is  apparent ;  the  yellow  tint  wholly 
goes,  the  cell  is  filled  by  a  somewhat  bright,  translucent  colourless 
material,  finely  granular  or  molecular  in  part,  and  the  outline  of  the 
cell  is  so  faintly  mapped-out  that  it  may  be  easily  overlooked.  These 
shrunken  cells  are  also  found  broken  up  into  little  heaps  of  colourless 
or  faintly-pigmented  disintegrated  molecules  {PL  xv.,  fig.  o). 

The  granular  pigment  in  the  fresh  sections  is  apparently  unafiected 
by  ether,  by  alcohol,  or  by  both  conjointly ;  nor  does  it  undergo  any 
obvious  change  with  caustic  soda  or  fuming  nitric  acid.  All  such 
pigmented  collections,  in  cells  advanced  in  degeneration,  show  a 
decided  darkening  when  treated  with  osmic  acid  (1  per  cent.),  and 
thus  reveal  a  certain  proportion  of  fatty  constituents;  whereas  the 
pale  cell,  full  of  translucent  material,  shows  decidedly  a  fatty  reaction 
when  so  treated.  "We  have  already  noted  that  the  pigmented  portion 
takes  up  none  of  the  usual  dyes — carmine,  luvmatoxylin,  or  aniline. 


476 


THK    MORBID    HRAIN    IN    INSANITY. 


To  summarise  briefly  the  changes  thus  undergone  by  the  cell,  we  may 
arrange  them  under  three  periods,  thus  : — 

Period  of  over  activity. —    (1. )  Swelling  of  cell  with  increase  of  pigment. 

Dark  stainingof  protoplasm,  nucleus, and  branches. 
(2. )  Advancing  degeneration,  cell  more  globose ;  jiroto- 
plasm  retracting. 
Sclerosic  investment  of  cell  and  cincture  formed. 
Period  of  diminished  activity. — Nucleus  eccentric,  deformed,  fatty,  with  narrow 

encircling  zone  of  protoplasm. 
Processes  few ;  these,  as  well  as  cell-protoplasm, 
faintly  stained. 
Period  of  absorption.  —  Fatty  transformation  and  decoloration  of  cell. 

Atrophy  with  shrinking  or  rupture  into  a  heap  of 
granules. 

During  the  progress  of  the  fatty  transformation,  vacuolation  of  the 
cell  not  infrequently  occurs ;  and  it  is  from  this  cause  that  it  appears 
occasionally  full  of  loculi,  the  fatty  contents  of  which  seem  to  have 
dropped  out  or  to  have  been  absorbed,  the  walls  or  dissepiments  of  the 
several  loculi  remaining  rigid.  Such  cells  present  a  very  extraordinary 
appearance  {Ph.  xi.,  xiii.),  and  we  are  ignorant  as  to  the  cause  which 
induces  this  transformation  rather  than  the  more  usual  fuscous  change 
and  atrophy. 

Developmental  Arrest  of  the  Nerve-Cell. — At  an  early  phase 

of  its  history  the  cortical  nerve-cell  of  the  human  subject  is  of 
spheroidal  contour,  its  basal  process  non-medullated,  and  the  cell 
itself  possessed  of  extremely  few  processes.  Not  only  so,  but  the  cells 
are  of  small  size,  and  are  much  more  uniform  in  their  dimensions 
throughout  the  depth  of  the  cortex  than  in  the  fully- developed  and 
adult  brain.  So  utterly  unlike  are  these  young  cells  to  the  form 
ultimately  assumed  in  the  fully-developed  stage,  that  the  one  cannot 
possibly  be  mistaken  for  the  other.  "When,  therefore,  this  type  of 
cell  prevails  at  a  later  period  of  life,  we  have  unanswerable  testimony 
to  its  arrested  development.  It  might,  of  course,  be  objected  that 
such  primitive  cell-forms,  occurring  in  youth  and  adult  life,  were 
products  of  a  retrogressive  process  and  not  absolute  proof  of  their 
arrested  development ;  and  this  view  might  be  supposed  to  be  streng- 
thened by  the  fact  that  in  the  granular  and  granulo-pigmentary 
degenerations  already  described  we  have  reproduced  inflated  cell- 
forms,  which  at  a  certain  stage  possess  characters  strongly  reminding 
us  of  the  primitive  cell. 

Such  a  conclusion  is,  however,  inadmissible,  since  these  degenerative 
processes  are  progressive,  and  result  in  the  complete  disintegration  of 
the  nervous  elements ;  since  we  And  in  these  cases  cells  side  by  side  in 


DEVELOPMENTAL    ARREST    OF    NERVE-CELLS.  477 

every  stage  of  degenerative  change  ;  and  since,  in  the  great  majority  of 
the  cells  involved,  special  features  present  themselves  which  are  not 
afforded  by  the  cells  of  stunted  cerebral  development  to  which  we  now 
allude. 

It  appears  to  us  that  too  little  attention  has  been  bestowed  upon 
this  important  evidence  of  developmental  arrest;  we  drew  attention 
to  its  occurrence  in  certain  instances  of  epileptic  idiocy  and  imbecility 
in  the  year  1879,*  and  since  this  period  we  have  had  frequent  oppor- 
tunity of  verifying  the  observations  then  made. 

The  condition  to  which  we  allude  we  find  restricted  to  the  con- 
vulsive neuroses  ;  hitherto  we  have  failed  to  note  its  presence  in 
simple  forms  of  COng-enital  defect  and  deaf-mutism;  all  the 
instances    falling    under    our    notice    being    subjects    of    epileptic 

idiocy. 

It  is  important  to  note,  in  the  first  place,  that  the  cortical  layers 
presenting  this  primitive  type  are  especially  the  second  and  the  third 
layers ;  the  larger  ganglionic  cells  are  usually  in  a  state  of  excessive 
pigmentation,  and  even  present  evidence  of  the  granular  degeneration 
such  as  we  usually  meet  with  in  epileptic  insanity ;  but,  apart  from 
this,  they  do  not  assume  the  characters  presented  by  the  elements  of 
the  superimposed  layers,  and  they  usually  retain  their  normal  outline. 

Our  first  glance  at  the  cortex  in  the  second  and  third  layers,  throuo-h 
a  low-power  objective,  suggests  to  the  mind  a  staining  of  the  nuclear 
elements  only,  the  faint  delineation  of  the  cell  escaping  attention ;  but 
it  soon  becomes  obvious  on  more  careful  search  that  the  nerve-cells  are 
there  in  apparently  undiminished  numbers,  but  the  majority  completely- 
unaffected  by  the  staining  reagent  employed.  Their  appearance  is 
made  obvious,  in  fact,  by  the  presence  of  pigmented  (or  else  colour- 
less, but  translucent  and  often  highly-refractile)  contents  which  com- 
pletely Jill  the  cell. 

We  have  alluded  to  these  cells  as  spheroidal,  and  in  many  instances 
such  is  the  case;  but,  perhaps,  the  slightly-pyriform  contour  pre- 
dominates. They  resemble,  in  fact,  a  number  of  delicate,  yellow, 
pear-shaped  bladders  suspended  by  a  stalk — the  stalk  being  the  faintly- 
stained  apex  process,  whilst,  at  the  junction  of  the  latter  with  the  cell, 
the  well-stained  nucleus  presents  itself.  The  only  elements  which 
stain  normally  with  the  aniline  dye  are  the  large  cells  of  the  fifth 
layer,  and  these  (as  before  stated)  are  often  degenerated. 

With  greater  amplification  the  cell-contents  are  found  to  be  granular 

throughout— not  as  in  the  degenerative  change  previously  described, 

such  as  exists  in  senile  atrophy,  limited  to  one  portion  of  the  cell,  and 

contrasting    strongly   with    the    stained    protoplasm   elsewhere,    but 

*  Brain,  Oct.,  1S79,  p.  371. 


478  TirK  MOHini)  iii;Ai\  in  insanity. 

unifoTinhj  and  coarsely  granular,  i-esolved  Ijy  high  jiowers  into  oval 
or  spherical  bodies  usually  2  /x  to  4  /x  in  diameter.  Such  granules  are 
often  highly  refractile  and  quite  colourless,  but  usually  are  pigmented 
of  a  bright  yellow  tint.  Certain  cells  exhibit  a  faint  staining  between 
these  granular  bodies,  giving  it  a  somewhat  reticulated  aspect ;  this 
undou1>tedly  indicates  the  existence  of  the  original  protoplasmic 
groundwork  of  the  cell  unaffected  by  pigmentary  or  fatty  change, 
and,  in  some  instances,  a  somewhat  dark-stained  border  surrounds  the 
cell,  forming  a  well-detined  outline — this  is,  however,  exceptional. 

The  eccentricity  of  the  nucleus  is  a  notable  feature,  its  usual  position 
being  at  the  junction  of  the  apex-pi'ocess  with  the  cell,  but  it  is  occa- 
sionally appressed  and  flattened  against  the  sides  of  the  cell ;  it  is  of 
fair  proportionate  size  in  most  cells,  is  deeply  stained  by  aniline,  and 
often  presents  one  or  more  refractile  spots  in  its  interior.  The  branches 
radiating  from  these  cells  always  stain  very  feebly,  are  very  delicate 
and  attenuated,  and  the  paucity  of  branches  is  one  of  the  most  notable 
features  of  the  cell ;  in  the  greater  number  of  instances  the  apex- 
process  is  alone  detected.  Most  cells  show  only  two  divergent  branches 
near  the  inferior  pole,  whilst  it  is  rare  to  meet  with  four  or  five  pro- 
cesses. We  may  thus  summarise  the  features  presented  by  these 
nerve-cells  of  the  upper  layers  of  the  cortex  : — 

(a.)  Spheroidal  or  pyriform  contour  of  cells. 

(6.)  Marked  eccentricity  of  nucleus,  usually  apical  in  position. 

(c.)  Coarse  granular  condition  of  contents. 

(c^.)  Pigmentation  universal,  or  indications  of  a  fatty  change  of 
protoplasm. 

(e.)  Great  paucity  of  branches. 

(/. )  Peculiar  characters  far  most  mai'ked  in  cells  of  second  and 
third  layers. 

We  have,  therefore,  in  the  upper  cellular  zones  of  the  cortex  in 
these  cases  of  mental  defect  associated  with  epilepsy  : — 

1.  The  primitive  type  of  cell  reproduced  as  regards  contour  and 
branching ; 

2.  But  stamped  of  a  deg'CnePate  type  by  the  granulo-pigmentary 
or  fatty  condition  of  its  contents. 

It  would  seem  to  us  that  the  latter  condition  is  not  an  active 
degeneration,  but  rather  the  natural  state  of  a  degenerate  type  of  cell, 
as  it  does  not  proceed  to  the  rapid  disintegration  of  cell-structure 
which  pertains  to  the  ordinary  granular  and  "fuscous  "  degenerations 
of  later  life ;  and,  as  we  have  seen,  it  is  not  at  any  time  found  as  a 
partial,  but  as  a  universal,  condition  of  the  cell-structure.  In  epileptic 
insanity  where  the  epilepsy  is  acquired  at  puberty  or  at  adult  age,  how- 
ever frequent  and  severe  the  convulsive  seizures,  however  long-standing 


VACUOLATION  OF  NKHVE-CELLS.  479 

such  phenomena  have  been,  we  never  find  reproduced  the  appearances 
above  detailed.  However  advanced  the  "fuscous  "  or  granular  chan^'e, 
we  find  the  degenerating  cells,  if  once  they  have  acquired  their  normal 
developmental  characters,  show  indications  of  the  mature  type  to  the 
very  end ;  and,  hence,  we  can  in  no  way  consider  the  very  peculiar 
conformation  of  these  cells  in  epileptic  idiocy  to  be  the  outcome  of  a 
primary  degeneration.  We  shall  again  allude  to  these  stunted  globose 
cells  when  dealing  with  epileptic  insanity, 

VaCUOlation  of  Nerve-Cells.— This  change  consists  in  the  ap- 
pearance within  the  nerve-cell  of  oval  or  perfectly-spheroidal  bodies, 
of  high  refractile  power  quite  unaffected  by  any  staining  reagent, 
colourless  but  lustrous.  In  many  cases  the  lustrous,  refractile  quality 
may  be  wanting,  and  it  is  then  evident  that  the  spheroidal  outline  is 
that  of  a  genuine  caviti/  or  vacuole,  from  which  the  former  contents 
have  been  removed,  or  escaped  by  rupture  ;  that  such  rupture  of  the 
cell  does  occur  is  sufficiently  evident  in  the  case  of  certain  elements 
where  an  incomplete  vacuole  is  apparent  along  the  border  of  the  nerve- 
cell,  which  is  interrupted  here  by  a  wide  opening  leading  into  the  cavity 
of  the  vacuole.  There  may  be  but  one  such  vacuole  formed  in  the 
cell-protoplasm,  but  we  frequently  find  many  such  within  each  cell ; 
and,  in  extreme  cases,  they  crowd  the  interior  so  as  to  present  the 
very  remarkable  appearance  indicated  in  the  accompanying  fio-ure, 
where  the  outlines  of  eighteen  vacuoles  were  seen  in  a  single  large  multi- 
polar cell.  The  removal  of  the  contents  of  such  vacuoles  may  be 
effected  by  reagents,  by  the  methods  of  preparation  of  the  section,  and, 
as  we  believe,  by  direct  absorption  during  life  through  the  agency  of 
the  lymph-connective  system.  However  removed,  it  is  evident 
that  the  original  cavity  maintains  its  former  contour,  and  is  never 
encroached  upon  by  the  protoplasm  surrounding  it ;  and  in  such  cases 
where  the  cavity  has  opened  up  on  the  outer  surface  of  the  cell  no 
retraction  of  the  protoplasm  occurs,  but  the  contour  is  rigidly  pre- 
served. The  protoplasm  surrounding  the  vacuoles  is  more  or  less  in 
a  state  of  granular  degeneration,  faintly  stained,  or  pigmented  and 
fuscous.  This  association  of  vacuolation  and  granular  degeneration  is 
invariable  (PL  xiii.) ;  yet  the  vacuoles  are  often  immediately  in 
contact  with  unaffected  protoplasm  which  assumes  a  deep-stained  tint, 
and  still  further  aids  in  bringing  thetu  into  relief  Tlie  nucleus  of  the 
cell  may  be  concealed  from  view  or  really  absent ;  usually  it  is  con- 
siderably displaced.  The  aspect  of  many  of  these  degenerated  cells  is 
suggestive  of  encapsulation,  through  the  formation  of  an  outer  deli- 
cate investing  pellicle  of  devitalised  protoplasm  (see  lower  three 
cells  in  PI.  xiii.).  The  granular  degeneration  and  the  resultintr 
vacuolation  and  feeble  staining  of  nerve-cells  indicate  a  fatty  chancre 


480  TiiK  MOinni)  huain  in  insanity. 

in  the  cell-protoplasm,  and  the  separation  of  the  fatty  matter  which 
fills  the  vacuole  can,  as  is  now  well  known,  be  artificially  induced  ; 
thus  in  phosp/iorus  poisoniny  we  are  aware  that  an  acute  fatty  degenera- 
tion occurs  in  the  tissues  from  an  increased  metamorphosis  of  albumen, 
but  chiefly  from  interference  with  the  oxidation  of  the  tissues,  and, 
hence,  the  accumulation  of  fat  within  the  cell.  This  is  mainly  due  to 
the  destruction  of  the  oxygen-carriers — the  red  blood-corpuscles — 
induced  by  phosphorus*  ( Voit  and  Bauer).  This  rapid  splitting-up  of 
the  protoplasm  of  the  cell,  and  the  accumulation  of  fat  within  its  struc- 
ture, is  equally  induced  in  the  nerve-cells ;  and  the  experiments  of  Voit 
and  Bauer  have  been  repeated  upon  dogs  and  rabbits  by  Popow,  Danilo, 
Kreyssig,  and  Flesch,  with  results  which  indicate  that  phosphorus 
and  arsenic  apparently  induce  a  granular  degeneration  and  vacuolation 
of  the  ganglion  cells  of  the  spinal  cord.  Flesch,  however,  and,  later 
on,  Trzebinski,  have  questioned  the  conclusions  arrived  at  by  other 
authorities,  and  would  assign  the  vacuolation  to  an  alteration  induced 
by  chrome  reagents.  The  latter  emphatically  asserts  that  in  fresh 
preparations  examined  by  him  the  change  was  never  witnessed.t  We 
have  on  the  contrary  not  only  constantly  met  with  vacuolated  cells  in 
fresh  frozen-sections  of  certain  subjects  of  insanity,  but  the  most  ex- 
tensive instance  of  this  degenerative  change  we  have  seen,  and 
which  we  have  figured  in  Plate  xii.,  was  treated  entirely  by  fresh 
methods  (sections  from  frozen  brain  being  stained  with  aniline 
blue  black).  We  are,  therefore,  assured  that  Flesch  is  certainly 
premature  in  the  conclusion  arrived  at,  viz.,  that  vacuolation  is  not 
met  with  in  nervous  tissues  examined  fresh,  but  is  presumably  induced 
by  hardening  reagents.  Trzebinski's  researches  indicate  that  these 
changes  may  be  imitated  by  the  use  of  chrome  reagents  in  healthy 
tissues  ;  but  they  do  not  prove  the  artificial  nature  of  these  changes 
in  diseased  nervous  centres,  since  we  repeatedly  meet  with  these 
vacuolated  cells  in  onv  frozen- sections  of  brain. 

The  vacuolation  is,  as  before  stated,  always  associated  with  the 
granular  degeneration,  although  the  latter  may  frequently  be  found  to 
afl^brd  no  instances  of  vacuolation.  We  meet,  therefore,  with  this 
change  in  the  cell  in  senile  cerebral  atrophy,  and  it  is  by  no  means  an 
infrequent  condition  in  the  insanity  of  chronic  alcoholism.  In  both 
cases  we  must  attribute  it  to  the  accumulation  of  hydrocarbon  in  the 
tissues  from  defective  oxidation,  which  is  the  invax'iable  sequel  to  old 
ace,  and  to  excessive  indulgence  in  alcohol. 

Vacuolation  of  Nucleus. — The  former  condition  is  usually  con- 

*  Zeitschrift  filr  Bioloijie,  vii.,  Voit  and  Bauer. 

\  Arch,  fur  Path.  Anal.  u.  Physiol,  u.  fiir  Klin.  Med.,  Bd.  cvii.,  H.I.  or  an 
abstract  of  the  paper  by  Dr.  Ernest  Birt  in  Brain. 


^■V  x' 


\    ....     •: 


A. 


■..^ 


J" 


VACUOLATION  OF  NUCLEUS.  481 

fined  to  the  nerve-cell,  the  nucleus  not  necessarily  being  implicated  in 
like  manner ;  and  it  is  a  feature  more  common  in  the  large  ganglionic 
cells  of  the  spinal  cord  or  the  motor  area  of  the  cortex  of  the  brain, 
than  in  the  cells  of  the  posterior  cornua,  or  of  the  superjacent  layers  of 
the  cortex ;  at  all  times  they  are  more  prominent  and  obtrusive 
appearances  in  the  former  positions. 

The  nucleus-change,  however,  is  one  peculiarly  common  to  the 
smaller  cells  of  the  upper  layers  of  the  cortex ;  and,  in  fact,  is  often 
limited  to  the  second  layer— the  small  angular  cells,  fringing  externally 
the  small  pyramidal  elements  of  the  third  layer.  It  is  exceptional 
to  find  so  notable  and  so  extensive  a  change  as  that  represented  in  PI. 
xii.  On  referring  to  that  drawing,  we  observe  that  almost  every  cell 
is  vacuolated ;  some  containing  several  vacuoles,  and  most  presenting 
unnatural,  distorted  outlines  as  the  result  of  the  change  undergone. 
It  will  also  be  observed  that  the  nucleus  is,  in  the  univacuolated 
cells,  the  primary  seat  of  disease ;  so  that  in  many  cases  the  whole 
nucleus  is  represented  by  a  spherical  vacuole,  and  the  cell,  in  lieu  of 
its  dark-stained  centre,  shows  an  unstained  bright  spheroid  surrounded 
by  the  stained  protoplasm  of  the  cell.  Early  indications  of  this  change 
are  revealed  by  a  minute  oily  droplet  in  the  centre  of  the  nucleus ; 
such  droplets  multiply  and  progressively  enlarge,  until,  no  longer 
coalescing  in  the  nucleus,  they  become  free  within  the  cell-protoplasm, 
which  is  also  found  in  a  state  of  granular  degeneration  (^Pl.  xii.). 
The  change  as  peculiarly  confined  to  the  nucleus  in  early  stages,  will 
be  more  carefully  considered  in  our  section  on  the  pathology  of  the 
insanity  of  epilepsy,  as  it  is  in  this  and  certain  other  convulsive 
afi"ections  that  we  meet  with  it  as  a  very  notable  and  uniform  change. 

It  may  at  first  appear  an  unnecessary  refinement  to  distinguish 
between  the  vacuolation  of  cell  and  of  nucleus  as  we  have  here  done ; 
both  are  indications  of  a  fatty  change  finally  producing  the  self-same  dis- 
integration. It  is,  however,  important  that  such  a  distinction  be 
drawn,  since  the  site  of  lesion  in  both  instances  appears  to  us  to 
indicate  a  wholly  dissimilar  origin.  The  fatty  disintegration  and 
vacuolation  of  the  large  ganglionic  cells  appear  to  be  induced  by 
changes  in  the  blood-corpuscles  leading  to  defective  oxygenation,  by 
chronic  pulmonary  afiections  acting  in  the  same  way,  by  the  efi'ects  of 
certain  poisons  (arsenic,  phosphorus)  or  any  of  the  many  circum- 
stances which  restrict  the  supply  of  oxygen  to  the  tissues ;  the  effect 
is  a  general  one,  but  those  elements  in  the  cortex  naturally  suffer 
earliest  and  most  severely  whose  nutrition  is  carried  on  at  greatest 
disadvantage.  This  is  peculiarly  the  case  with  all  the  large-sized  cells 
of  the  cortex,  whose  bulk  and  greater  distance  from  the  arterial  twigs 
is  inimical  to  rapid  restoration  of  nutritive  equilibrium,  as  long  since 

31 


482  TIIK    MORBID    BRAIN    IN    INSANITY. 

indicated  by  Dr.  Ro.ss.*  These  large  cells,  therefore,  are  the  first  to 
succumb  to  fatty  change  induced  by  any  general  effect  restricting 
oxidation. 

When,  however,  we  meet  with  a  special  layer  of  the  cortex,  and 
more  especially  of  its  smallest  nerve-elements  so  affiected,  the  same 
explanation  is  not  valid ;  we  cannot  imagine  these  minute  elements 
suffei'ing  so  extensively,  whilst  the  larger  escape  from  any  wide- 
spread defect  in  oxygenation.  We  can  only  here  presume  that  the 
change  induced  is  indicative  of  an  intrbisic  morbid  factor  in  tJie  cell 
itself,  or  of  its  immediate  structural  connections.  Hence  we  regard 
the  changes  found  in  senile  atrophy  of  the  brain-cell  as  having  an 
entirely  different  significance  to  those  found  in  epilepsy  and  iu  chronic 
alcoholic  insanity  ;  in  the  latter  we  do  not  look  for  a  cause  of  the 
degenerative  change  in  the  blood  or  vascular  apparatus,  but  in  some 
primary  condition  of  the  nervous  arrangements  in  themselves. 

Destruction   of  Nerve-Fibre    Plexus. — In   cases  of  chronic 

insanity,  and  especially  where  atrophy  is  a  prominent  feature  in  the 
cerebral  hemispheres,  the  fresh  cortex  obtained  by  freezing,  and 
stained  by  aniline  blue-black,  shows  highly-characteristic  appear- 
ances. In  healthy  brain  a  clear  differentiation  of  the  nervous  elements, 
the  cell  and  nerve-fibre  plexus,  prevails,  when  fresh  sections  are  so 
•  treated ;  they  appear  darkly-stained,  and  imbedded  in  a  clear,  un- 
stained matrix,  in  which  connective  nuclei  and  meandering  vessels 
are  less  obviously  defined.  In  the  chronic  atrophic  diseases  of  the 
cortex  associated  with  insanity  the  aspect  is  very  different.  Here  we 
find  much  diffusiveneSS  of  staining,  the  matrix  being  uniformly 
-affected  by  the  aniline,  or  exhibiting  a  patchy  mottling  of  a  deep 
aniline  tint  separated  by  perfectly  light  or  faintly-tinted  areas. 

In  consequence  of  this  diffuse  staining  of  the  matrix,  which  often 
approaches  the  depth  of  tint  assumed  by  the  nerve-cell,  the  differen- 
tiation of  the  latter  is  greatly  impaired ;  and  we  have  known  these 
specimens  thrown  aside  as  badly-prepared  sections,  the  blurred  and 
indistinct  elements  being  regarded  as  failures  in  staining  rather  than 
the  results  of  morbid  change.  In  all  advanced  cases  the  uniform 
diffusiveness  of  staining  is  much  intensified  by  the  degenerative 
changes  proceeding  in  the  nerve-cell  and  its  network  of  branches ; 
but,  it  is  important  to  note,  that  the  former  long  survives  the  latter 
as  an  essential  though  diseased  element  in  the  cortex.  It  is  the 
fibre-plexus  formed  by  the  radiating  processes  (not  the  primary  but 
the  secondary)  which  are  earliest  implicated,  and  we  frequently  note 
their  almost  entire  absence  from  the  field,  whilst  the  degenerate  cell 
remains  in  various  stages  of  decay. 

*  Diseases  of  ilte  Nervous  System,  vol.  i. 


DESTRUCTION    OF    NERVE-FIBRE    PLEXUS.  483 

In  cases  of  secondary  dementia,  we  always  note  the  appearances 
now  detailed,  especially  in  the  anterior  sections  of  the  hemispheres ; 
there  is  the  great  paucity  of  cell-processes,  the  patchy  mottling  of  the 
intercellular  areas  of  the  matrix,  an  increase  in  nuclei,  and  the  field 
strewn  with  the  faintly-stained,  indefinite,  blurred  outline  of  degener- 
ating nerve-cells.  The  patchy  mottling,  on  closer  examination,  resolves 
itself  into  the  fine  fibrillar  meshwork  which  originates  from  the 
scavenger-elements  (spider-cells),  and  which  has  replaced  the  non- 
medullated  meshwork  intervening  between  the  nerve-cells :  but  partly 
into  coarser  patches  resulting  from  the  disintegrated  nerve-cells,  which 
have  entirely  lost  all  semblance  of  their  former  outline,  or  being 
well-defined  in  their  lower  half,  become  indistinct  above,  and  fade  ofi" 
imperceptibly  into  the  surrounding  matrix;  or  they  may  have  attached 
to  them  a  few  shrunken  nuclei  as  sole  representatives  of  the  spider- 
cells  which  attacked  them  at  an  earlier  stage. 

The  fact  last  alluded  to  is  important.  It  must  be  borne  in  mind 
that  these  destructive  elements  have  but  a  transient  period  of  exist- 
ence, and  the  more  actively  they  play  the  part  of  scavengers  on  the 
neighbouring  tissue,  the  more  rapidly  (we  may  assume)  do  they 
fibrillate  and  lose  their  cellular  constitution,  passing  in  this  stage 
through  a  fatty  transformation  like  the  nerve-cell  {PI.  xv..  Jig.  2). 

In  advanced  instances  of  this  interstitial  atrophy,  we  consequently 
may  find  few,  if  any,  of  these  characteristic  organisms  present  them- 
selves ;  but  the  resulting  fibrillar  meshwork  is  always  perceptible. 
The  fatty  change  of  these  tissue-elements  involves  considerable  dis- 
coloration by  the  use  of  osmic  acid,  which  is  requisite  in  the  fresh 
process  of  examination,  and  it  therefore  becomes  imperative  that 
a  very  dilute  solution  of  the  reagent  be  employed,  unless  the  firmness 
of  tissue  permits  of  its  being  entirely  dispensed  with ;  if  the  usual 
•5  per  cent,  solution  be  employed,  great  obscuration  of  the  tissue- 
elements  may  result. 

The  delicate,  unprotected  processes  of  the  intercellular  nerve-plexus 
lend  themselves  most  readily  to  the  ravages  of  the  scavenger-cells ; 
they  succumb  sooner  than  the  apex-process,  the  cell  itself,  and  the 
basal  axis-cylinder  process,  which  persist  latest  [PL  x.y.,Jig.  1).  Hence, 
as  we  shall  find  in  most  instances  of  secondary  dementia,  it  is  this 
plexus  which  is  earliest  and  most  exposed  to  decay,  and  from  it  issues 
that  interstitial  atrophy  which  progressively  advances  to  the  termina- 
tion of  the  case ;  it  is  a  destruction  of  tissue  which  can  never  be 
replaced. 

A  due  estimate  of  the  nerve-cell  as  the  elementary  unit  of  the 
nervous  mechanism  is  now  universally  recognised  as  essential  to  an 
intelligent  appreciation  of  the  phenomena  of  cerebral  activity,  whether 


484  THE    MOIiBID    15KAIN    IN    INSANITY. 

from  the  physiological  or  pathological  standpoint.  That  the  absence 
of  the  elaborate  cell-mechanisms  of  the  cortex,  and  their  imagined 
replacement  by  a  perfectly  homogeneous  structureless  matrix  in  which 
the  nerve-fibres  lost  themselves,  would  introduce  into  our  problems  in 
the  present  state  of  physiological  science,  inextricable  confusion,  is  self- 
evident  ;  since  the  phenomena  of  functional  differentiation  would  then 
remain  to  us  a  profound  mystery,  and  the  simplest  correlations  of  mind 
would  await  an  explanation. 

If  for  these  reasons  only,  we  may  safely  exalt  the  nerve-cell  to 
a  position  of  the  very  highest  importance  in  our  problems  of  mind.  It 
is  on  this  account  highly  important  that  the  nerve-cell  of  the  cerebral 
cortex  should  be  the  subject  of  careful  study  by  all  interested  in 
psychological  medicine ;  and  that  due  attention  should  be  paid  to 
the  conditioning  of  its  functional  activities,  and  to  the  results  of  its 
nutritional  impairment,  disease  and  death. 

In  our  chapter  on  the  histology  of  the  cortex,  we  have  dwelt 
sufficiently  upon  this  structural  unit  in  its  relationships  to  the  sur- 
rounding elements,  to  indicate  the  intricacy  and  delicate  adjustment 
established  betwixt  it  and  its  physiological  environment.  Suspended 
within  a  sac  in  direct  connection  with  the  lymph-channels  surrounding 
the  blood-vessels — or  rather  its  own  special  nutrient  capillary — the 
nerve-cell  becomes  liable  to  any  influence,  however  trivial,  disturbing 
the  blood-stream  in  its  neighbourhood  {PL  v.).  A  quickened  circulation, 
a  retarded  flow,  an  ansemic  state  of  cortex  must  influence  the  functional 
activity  of  these  centres  of  feeling  and  thought ;  a  vitiated  quality  of 
the  blood,  or  the  presence  of  toxic  agents  introduced  from  without,  or 
elaborated  within,  the  economy  will  all  affect  them  in  a  greater  or  less 
degree ;  whilst  the  activity  of  the  lymph-connective  system  in  the 
removal  of  the  effete  products  of  functional  wear  and  tear,  will  play  an 
all-important  role  in  the  same  direction. 

That  delicate  system  of  lymph-COnnective  elements,  to  which 
we  have  alluded  as  permeating  (in  the  normal  state)  the  whole  of  the 
cerebral  mass  of  white  and  grey  substance,  takes  a  more  active  share 
in  the  pathogenesis  of  mental  decadence  than  any  other  :  and  the 
more  the  question  is  investigated,  the  greater  importance,  we  feel  con- 
vinced, will  be  attached  to  these  elements  in  the  processes  of  disease 
as  afiecting  the  nervous  centres.  Their  physiolog'ical  indications 
are  clear;  they  are  the  SCaveng'ePS  Of  the  brain;  and  the  evidence 
obtainable  renders  it  now  incontrovertible  that  they  are  liable  to  exces- 
sive and  rapid  development  under  certain  morbid  conditions  affecting 
cerebral  nutrition  and  repair.  In  the  normal  condition  of  healthy 
cerebration  these  elements,  far  from  being  obtrusively  present,  are 
so  delicate  and  pellucid  that  they  often  escape  detection ;   but  that 


TISSUE-DEGRADATION    AND    OVER-STRAIN.  485 

they  are  universally  present  can  be  readily  verified  by  special  methods 
of  examination. 

Whatever  leads  to  increased  waste  of  cerebral  neurine  ;  whenever 
structural  disinteg'ration  is  slowly  proceeding  either  in  nerve- 
cell  or  fibre ;  whenever  accumulation  of  debris  occurs  from  disease 
of  the  vascular  tracts,  then  we  invariably  note  an  augmented  activity 
registered  in  these  SCaveng-er-elementS  of  the  brain.  That  their 
activity  is  in  direct  ratio  to  the  functional  activity  of  the  essential 
neurine  tissue,  we  think  there  can  be  no  doubt ;  nor  that  with  each 
accession  of  the  nerve-tide  they  are  stimulated  to  increased  activity 
in  the  removal  of  the  products  of  waste  and  the  plasma  effused  from 
the  vessels.  In  healthy  states,  however,  they  never  assume  the  hyper- 
trophied  form,  the  deep  staining,  the  coarse  fibrillation,  the  rapid 
multiplication,  and  the  evidence  of  obvious  intracellular  digestion, 
which  are  so  readily  observed  in  pathological  states  {PL  xvii.). 

Tissue-Degradation  from  Over-strain.— In  certain  pathological 

states,  notably  in  general  paralysis,  we  shall  find  that  these  organisms 
play  an  all-important  part,  and  are  most  prominent  factors  in  the 
morbid  process;  but,  we  desire  here  to  draw  attention  to  their 
connection  with  certain  states  on  the  very  borderland  of  pathology, 
viz.,  instances  of  "  over-strain,"  where  cerebral  activity  has  been  too 
long  or  too  intensely  encouraged,  and  mental  tension  has  been  associated 
with  worrying  and  distracting  circumstances.  In  such  cases,  as  aU  of 
us  are  aware,  there  is  a  risk  of  permanent  damage,  and  most  of  us 
are  acquainted  with  instances  of  such.  That  sustained  mental  work 
indulged  in  by  the  healthiest  subjects,  yet  with  disregard  to  physio- 
logical laws,  will  reach  (if  persisted  in)  a  limit  where  the  pathological 
barrier  is  passed,  is  undoubtedly  true ;  but,  that  the  introduction  of 
the  element  of  worry,  interfering  with  the  smooth  current  of 
intellectual  work,  has  a  specially  vicious  influence  in  this  direction 
is  a  fact  of  such  far-reaching  consequences,  that  it  cannot  be  too 
forcibly,  or  too  often,  insisted  upon.  No  amount  of  rest  from  mental 
labour,  no  change  of  circumstances,  nor  absence  of  all  disturbing 
agencies  will,  in  the  cases  we  refer  to,  restore  the  mental  faculties  to 
their  former  vigour ;  it  would  seem  that  an  actual  destruction  of 
tissue  has  occurred  as  completely  as  if  excised  by  the  scalpel,  and 
that  restitution  to  the  former  state  is  impossible.  We  believe 
that  in  such  instances  an  actual  degenei-ation  of  cerebral-tissue 
has  been  entailed,  that  the  lymph-connective  system  has  received 
just  such  a  stimulus  beyond  the  physiological  limits  necessary  to 
ordinary  repair,  that  these  physiological  units  become  pathological 
factors,  and  the  nervous  elements  themselves  succumb  to  their 
rapacity. 


486  THE    MORBID    BRAIN    IN    INSANITY. 

Tissue-Deg-padation  from  Active  Patholog'ical  Processes.— 

In  consecutive  dementia  fullowing  upon  acute  insanity,  we  have 
evidence  tliat  what  we  have  portrayed  above  occurs  to  a  very  wide 
extent  in  the  cortex  of  the  cerebrum.  That  it  occurs  in  a  minor 
degree  in  all  attacks  of  mania  and  acute  melancholia  is  also  very 
probable,  judging  from  the  almost  invariable  signs  of  instability,  and 
slight  enfeeblement  of  potential  nerve-energy  in  most  apparent  re- 
coveries ;  but  for  consecutive  dementia  the  actual  fact  stands  out  as  a 
prominent  and  highly-significant  feature,  that  there  is  very  obvious 
destruction  of  the  nerve-fibre  plexus  of  the  coi'tex,  and  that  the 
intercellular  elements  have  degraded  in  type  to  the  purely  connective, 
or  have  undergone  fatty  disintegration  and  removal. 

We  regard  the  appearances  presented  by  such  cases  (already 
described,  p.  482)  as  indications  of  the  storm  which  overswept  the 
region,  and  as  evidence  of  repeated  engorgement  of  the  cortical  vessels 
attendant  upon  the  hyper-activity  of  the  nerve-elements.  We  see  in 
such  instances  the  coarse  and  tortuous  blood-vessels,  the  frequent  minute 
extravasations  and  deposits  of  hsematoidine  in  their  neighbourhood, 
and  other  changes  incideiit  to  bygone  attacks  of  excitement ;  but,  in 
the  presence  of  the  spider-cells  and  the  degraded  type  of  tissue,  we 
see  an  actively-destructive  agency  at  work,  which  has,  therefore,  a 
very  different  significance  to  the  vascular  changes  associated  therewith. 

In  no  case  of  acute  uncomplicated  mania  or  melancholia,  fatal  in 
early  days,  have  we  met  with  these  organisms  as  pathological  factors ; 
it  would  seem  that  the  normal  elements  play  their  part  as  tissue- 
scavengers,  with  a  fair  promise  of  success  up  to  a  certain  limit  of  time. 
In  fact,  the  duration  of  the  excitement  is  of  primary  importance 
in  the  elaboration  of  these  morbid  factors  ;  this  we  shall  have  occasion 
to  see  again  and  again  in  our  clinical  studies  of  insanity,  where  the 
time-element  is  of  such  great  moment  that  it  is  customary  to 
assume  (arbitrarily  of  course,  for  many  exceptions  occur)  that  cases  of 
mania  of  over  twelve  months'  duration  may  be  relegated  to  the 
chronic  class  of  the  insane.  There  is,  indeed,  but  little  doubt  that 
'  beyond  a  certain  period,  varying  for  each  individual's  neurotic  resist- 
ance (whether  it  be  within  or  beyond  twelve  months'  duration  of 
mental  excitement),  these  elements  multiply  and  take  up  a  pathological 
role,  preying  upon  the  tissues  whose  functional  integrity  in  health 
they  subserve. 

Another  factor  should,  however,  be  taken  into  account  in  this  con- 
nection, viz..  Age.  The  tendency  in  advancing  age  is  towards  a 
multiplication  or  overgrowth  of  these  elements,  so  that  in  senile 
dementia  (as  we  shall  see)  they  form  the  natural  associates  of  the  atro- 
phic changes  which  accompany  the  decadence  of  mind.     This  tendency 


TISSUE-DEGRADATION    FROM    DISUSE.  487 

is,  therefore,  emphasised  in  all  acute  insanities  occurring  in  advancing 
years;  and  we  may  regard  age  as  an  important  element  in  determin- 
ing the  consecutive  dementia  resulting  from  all  forms  of  insanity. 

Tissue-Deg"Padation  from  Disuse.— The  process  we  have  been 

considering  is  one  of  genuine  degradation  of  tissue  preceded  by  over- 
stimulation of  cortical  areas ;  but,  a  degradation  in  type  may  also  be 
slowly  induced  (according  to  well-known  physiological  principles)  by 
lowered  functional  activity  or  disuSG.  The  atrophic  changes  then 
resultant  are  induced  through  the  agency  of  the  same  scavengez-- 
elements  which  remove  the  degenerating  tissues  and  replace  them  by 
their  own  fibrillated  stroma.  We  are  thus  inclined  to  explain  the 
profusion  of  these  spider-elements  in  the  cortex  of  most  domesticated 
animals,  notably  in  the  sheep  and  in  the  tame  rabbit.  In  the  former, 
the  pia  is  firmly  attached  to  the  surface  of  the  brain  by  these  elements, 
and  requires  considerable  force  for  its  removal ;  in  the  latter,  sections 
through  the  cortex  exhibit  them  in  great  abundance  in  the  peripheral 
zone.  Similarly  they  are  to  be  noted  in  the  cat,  dog,  ox,  and  monkey 
in  varying  degrees.  Sir  J.  Crichton-Browne  has  called  attention  to 
the  disparity  in  weight  between  the  brain  of  certain  wild  and  domesti- 
cated animals,  taking  as  a  forcible  illustration  the  reduced  weight  of 
the  brain  of  the  tame,  domesticated  duck  as  contrasted  with  that  of  its 
wild  representative.  The  decadence  from  disuse  of  certain  faculties 
essential  in  the  wild  state  is  thus  actually  expressed  in  weight,  and  we 
might  infer  that  in  all  alike  a  degradation  of  tissue  initiates  such 
atrophic  changes.  In  man  a  similar  change  suggests  itself  as  occur- 
ring in  those  instances  where  a  long  life  of  unusual  mental  and  bodily 
activity  has  been  suddenly  interrupted  by  circumstances  which  restrict 
within  an  extremely  limited  range  his  further  activities;  in  such 
instances,  how  frequently  do  we  date  the  first  evidence  of  mental 
decadence  from  the  cessation  of  the  customary  active  life  of  the 
individual.  The  preference  to  "die  in  harness,  rather  than  rust"  is 
a  trite  saying,  dictated  by  a  full  appreciation  of  the  physiological 
principle  of  the  decline  of  faculties  with  their  disuse. 

Since  then,  these  lymph-connective  elements  play  so  important 
a  rtle  in  the  degenerations  of  cerebral  tissues  in  mental  disease,  it 
becomes  an  interesting  question  to  inquire  how  far  their  pathological 
development  may  reveal  itself  to  the  naked-eye  examination  of  the 
morbid  brain  1  The  presence  of  unnatural  attachments  betwixt  the 
pia-arachnoid  and  subjacent  cortex  as  morbid  adhesion  is  conclusive 
evidence  of  the  presence  of  these  pathological  elements ;  even  undue 
firmness  of  connection,  apart  from  actual  adhesion,  may  indicate  their 
presence  (as  we  have  seen,  occurs  in  the  brain  of  the  lower  animals), 
but  their  presence  in  the  cortex  already  softened  by  an  acute  process, 


488  THE    MORBID    BRAIN    IN    INSANITY. 

such  as  occurs  in  general  paralysis  of  the  insane,  is  accompanied  by 
the  most  pronounced  appearances  of  morbid  connection. 

Yet,  although  their  presence  is  confirmed  by  the  morbid  adhesions 
so  affected,  it  by  no  means  follows  that  the  absence  of  adhesion 
necessarily  excludes  them  from  this  site;  in  fact,  these  elements  in 
a  state  of  morbid  proliferation  in  the  outer  zone  of  the  cortex  may  be 
frequently  seen  where  no  suspicion  of  adherent  membranes  exists  {PI. 
XV.,  fig.  2).  In  the  latter  case,  their  appearance  is  usually  coincident 
with  considerable  fatty  disinteg'Pation  of  tissue,  these  elements 
themselves  succumbing  to  this  change,  and  very  considerable  inter- 
stitial atrophy  is  apparent. 

Another  indication  of  the  ravages  of  these  scavenger-cells  is  afforded 
by  the  various  atrophic  states  presented  by  the  cortex  of  the  chronic  insane 
— of  course,  exclusive  of  such  atrophy  as  is  dependent  upon  obviously 
gross  lesions — apoplectic  foci,  softened  tracts,  (kc.  [PI.  xv.,Jig.  1).  Such 
atrophy  is  always  attendant  upon  the  degradation  of  tissue  to  which  we 
now  refer,  and  its  distribution  maps  out  with  tolerable  accuracy  the 
areas  chiefly  implicated  by  these  agencies ;  and,  moreover,  the  localisa- 
tion of  such  wasted  areas  has  an  important  bearing  upon  the  history  of 
the  acute  attack  preceding  the  consecutive  atrophic  change.  It  is  also 
a  very  noteworthy  feature  with  respect  to  the  degradations  of  tissue  so 
resulting,  that  the  peripheral  zone  of  the  cerebral  cortex  is  far  more 
prone  to  implication  than  deeper  regions,  at  an  early  stage  of  the 
process ;  eventually  these  elements  attack  the  deeper  layers  and  the 
medullary  strands,  but  their  destructive  agency  is  chiefly  exhausted 
upon  the  nerve-fit)Pe  plexus  formed  by  the  naked,  unprotected 
processes  of  the  cells.  The  importance  of  this  fact  is  at  once  evident 
when  taken  in  connection  with  the  prevailing  view  as  to  the  autonomy 
of  the  cell  and  the  significance  of  its  ramifying  processes  ;  the  cell 
represents  the  sensOPy  unit  of  mind,  and  the  processes  whereby  its 
connection  with  similar  units  is  effected  represent  the  relational 
element  of  mind,  the  means  whereby  a  change  from  one  state  of 
feeling  to  another  is  rendered  possible.  With  the  breaking-down  of 
these  nerve-fibre  plexuses  the  relational  element  of  mind  progressively 

suffers,   the   intellectual    vig-oup   wanes ;    whilst  the    pupely 

sensuous  element  may  long  hold  its  own. 

The  nerve-cell  itself  eventually  succumbs  to  a  disintegrating  process, 
possibly  secondary  to  the  destruction  of  its  processes ;  and  (as  we  have 
already  indicated,  p.  483)  relics  of  such  cells,  in  all  stages  of  dissolu- 
tion, are  to  be  seen  scattered  throughout  the  cortex  in  advanced  cases 
of  consecutive  dementia.  The  tissue-destruction  is  of  such  a  nature  as 
not  to  lend  itself  to  the  processes  of  repair ;  and,  in  the  appearances 
so  presented,  we  must  learn  to  recognise  a.  permanent  mental  enfeeblement. 


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PATHOLOGICAL    INDICATIONS — SUMMARY.  489 

From  the  clinical  and  pathological  aspects  of  acute  and  chronic 
insanity  we  feel  justified  in  making  the  following  assumptions  : — 

(1)  Acute  insanity  may  be  regarded  as  a  very  general  implication 
of  the  sphere  of  mind,  and  hence  of  a  wide-spread  disturbance  of  the 
cerebral  cortex. 

(2)  Its  operation  is  decidedly  concentred  upon  the  motOP  or 
fponto-parietal  section  of  the  hemispheres,  judging  from  the  dis- 
position of  morbid  appearances  and  the  resultant  atrophy  of  the 

secondary  dementia. 

(3)  That  in  certain  forms  of  mental  derangement  (the  fulminating^ 
psychoses  as  they  may  be  termed)  approximating  to  the  epileptic 
and  convulsive  neuroses  in  their  character,  a  more  local  Orig'in  is 
often  presumable ;  and  in  such  instances  we  often  find  sensory  areas 
peculiarly  prone  to  implication. 

(4)  That  even  in  the  more  universal  implication  of  acute  insanity, 
the  full  force  of  the  nerve-storm  falls  with  unequal  strength  upon 
special  areas ;  as  indicated  in  the  uncured  wrecks  of  our  asylum 
chronics,  whose  brains  exhibit  a  very  variable  and  unequal  distribu- 
tion of  the  wasted  areas. 

(5)  In  its  destructive  implication  of  the  cortex,  it  is  the  inter- 
cellular nerve-fibre  plexus  (the  relational  element)  which  primarily 
and  principally  sufiers. 

(6)  That  the  atrophic  state  induced  in  the  consecutive  forms  of 
dementia  results  in  a  greatly-diminished  brain-weight,  as  long  since 
indicated  by  Sir  J.  Crichton-Browne.* 

Let  us  consider  these  more  in  detail.  Our  studies  of  the  pathology  of 
insanity  would  impress  us  with  the  important  principle,  that  whenever 
the  nervous  elements  of  the  cortex  are  primarily  the  seat  of  disease 
originating  mental  derangement,  then  the  implication  of  the  sphere  of 
mind  tends  always  to  be  more  generally  or  universally  involved ;  but 
that  where  the  nerve-changes  are  secondarily  induced  as  the  result  of 
vascular  disease,  the  greater  tendency  is  shown  towards  a  local  or 
partial  implication  of  that  sphere.  In  the  former  case,  the  intimate 
connection  of  the  nervous  system  may  partly  explain  this  more  general 
implication,  as  it  is  scarcely  possible  for  any  serious  affection  of  any 

*  The  statement  made  by  Sir  Crichton-Browne  is  to  this  effect: — "  Consecutive 
and  chronic  dementia,  a  form  or  forms  of  mental  disease,  embracing  so  many  of  the 
inmates  of  our  lunatic  hospitals,  whose  nervous  systems  have  been  inseparably 
damaged  by  the  acute  storms  of  disease,  or  who  have  subsided  quietly  into  the 
depths  of  fatuous  degeneration,  is  represented  in  Table  vi.  by  a  brain-weight  only 
a  shade  greater  than  that  of  organic  dementia;  the  average  for  males  being  1.315"3 
grammes,  and  for  females  1159"5  grammes."  Brain,  vol.  ii.,  "  On  the  Weight  of 
the  Brain  and  its  Component  Parts  in  the  Insane." 


490  THE    MORBID    URAIS    IN    INSANITY. 

cortical  area  to  be  established  without  involving  neighbouring  and 
distant  territories  closely  associated  in  their  functional  activities,  and, 
therefore,  in  organic  connection  with  each  otlier ;  but,  in  the  latter 
case,  the  territorial  independence  of  the  arterial  supply  and  the  ter- 
minal nutrient  twigs  of  the  cortex  impose,  as  is  well  known,  a  localising 
character  upon  most  of  the  nervous  affections  originating  in  vascular 
lesion.  Hence  we  find  that,  whereas  in  ordinary  uncomplicated  acute 
insanity  (acute  mania  or  melancholia)  the  territorial  implication  is  a 
Vepy  g'eneral  one,  although  invariably  expressed  at  certain  sites 
more  than  at  others ;  yet,  that  in  certain  insanities  {e.g.,  that  accom- 
panying general  paralysis),  special  sites  of  election  are  taken  by  the 
diseased  process,  one  area  being  affected  after  the  other,  until  ultimately 
the  localising  character  of  the  ailment  fades  into  a  widespread,  general 
implication.  So,  again,  in  alcoholic  insanity,  the  resulting  dementia  is 
peculiarly  apt  to  exhibit  this  partial  and  restricted  Character 
(especially  in  certain  forms  of  amnesia  to  which  we  have  previously 
alluded) ;  upon  the  other  hand,  the  gradually  advancing,  yet  universal 
implication  of  mind  in  the  decadence  of  senile  atrophy  would  imply 
not  as  in  the  former  a  vascular,  but  a  primarily  nerVOUS  orig"in. 

This  tendency  of  primary  nervous  implication  to  share  in  the 
universality,  which  also  characterises  nervous  affections  of  hjfimic 
origin,  should  not  blind  us  to  the  fact  already  emphasised,  that  in  the 
widest-spread  mental  disturbance  the  morbid  implication  is  always 
more  strongly  expressed  in  certain  directions  than  in  others ;  and  that, 
in  a  certain  sense,  we  may  with  propriety  speak  not  of  insanity  l)ut 
of  insanities,  multiform  in  their  nature,  and  all  pointing  to  certain 
definite  weakened  areas  in  the  material  substrata  of  mind.  In  this 
sense  we  have  long  been  accustomed  to  appreciate  Dr.  Hughlings- 
Jackson's  dicta  when  dealing  with  the  reductions  of  insanities ;  and  in 
this  connection  "a  plea  for  the  minute  study  of  mania,"  by  Sir  J. 
Crichton-Browne,  is  well  worthy  of  attention.*  It  is  in  this  direction 
that  we  may  yet  hope  for  much  enlightenment  at  the  hands  of 
clinical  observers  upon  the  question  of  cerebral  localisation,  or,  at  all 
events,  for  facts  confirmatory  of  the  results  of  experimental  enquiry. 
Dealing,  however,  as  we  do  here  with  mental  operations  the  alienist 
has  a  field  before  him  which  extends  far  beyond  the  present  limits  of 
possible  physiological  experimentation. 

The  superficial  wasting  of  the  cerebral  hemispheres  in  insanity  is  far 
more  general  and  extreme  in  the  fronto-parietal  segment  of  the  brain ; 
in  fact,  as  we  have  before  seen,  in  three-fourths  of  all  cases  of  cerebral 
atrophy  we  find  the  wasting  limited  to  this  division.  It  is  the  so-called 
motor,  and  intellectual,  and  inhibitory  sections  of  the  hemisphere  j'^'f 

*  Brain,  vol.  iii. 


PATHOLOGICAL    INDICATIONS — SUMMARY.  491 

excellence  which  suffer  most  severely  as  the  result  of  acute  insanity  and 
its  sequelae ;  not  the  assuined  sensory  section.  The  more  localised 
wasting,  on  the  other  hand,  where  limited  to  individual  gyri,  exhibits 
the  same  tendency  to  locate  itself  in  motor  areas,  affecting  in  order 
of  frequency  the  centres  for  the  (a.)  lower  extremities ;  (b.)  the  upper 
extremities;  (c.)  the  face  and  tongue;  whilst  the  separate  frontal  gyri 
come  in  order  of  frequency  between  the  two  latter.  Last  of  all  come 
the  sensory  areas  of  the  temporo-sphenoidal,  occipital,  and  angular 
regions  (fig.  13,  p.  457). 

A  very  different  feature  is  presented  by  the  localised  softenings, 
due,  in  far  the  greater  proportion  of  cases,  to  thrombosis  of  the 
cerebral  vessels.  Here  it  is  distinctly  seen  (fig.  11,  p.  452)  that  the 
sensory  areas  of  the  upper  temporo-sphenoidal,  occipital  and  cuneate 
divisions  are  most  prone  to  become  involved ;  the  motor  areas  of 
the  ascending  frontal  and  postero- parietal  following  in  their  turn. 
In  mental  derangements  associated  with  (1  determined  by)  these 
vascular  affections,  therefore,  we  find  the  most  persistent  hal- 
lucinations of  hearing" ;  and  this  is  a  suggestive  feature  taken 
in   connection   with   the   proneness  to  the  implication  of  the  fourth 

or  sphenoidal  branch  of  the  middle  cerebral,  and  the  occipital 

division  of  the  posterior  cerebral  arteries.  Alcoholic  insanity, 
perliaps,  affords  us  the  best  instances  of  the  kind.  What  it  is  that 
determines  the  more  frequent  implication  of  these  arterial  channels 
than  the  other  branches  of  the  same  trunk,  we  cannot  at  present 
even  surmise. 

With  respect  to  the  question  of  localisation  as  affecting  the  frontal 
division  of  the  hemispheres,  it  will  be  occasionally  found  that  the 
atrophic  sequelae  of  insanity  exhibit  a  very  notable  wasting"  of  the 
frontal  lobes  ;  the  atrophy  to  which  we  allude  is  so  extreme  as 
to  give  this  lobe  a  peculiar  pointed  aspect,  reminding  one  strongly 
of  the  cerebrum  in  the  i^abbit  as  regards  its  general  outline.  We 
have  met  with  several  instances — three  especially  marked  cases — of 
this  extreme  atrophy  of  the  frontal  lobe.  Its  importance  depends 
upon  the  constant  association  of  a  definite  series  of  symptoms,  which 
seem  to  us  to  have  a  localising  significance  and  to  which  we  drew 
attention  in  a  former  article  on  cerebral  localisation.*  The  symptoms 
to  which  we  refer  comprise  a  peculiar  form  of  dementia,  in  which 
extreme  somnolence  prevails,  and  an  utter  incapacity  for  the 
most  trivial  mental  effort.  Unlike  many  dements,  their  attention 
can  scarcely  be  even  momentarily  aroused,  and  then  only  to  be 
followed  by  a  lapse  into  the  profound  torpor  which  simulates  sleep. 
This  condition  of  somnolence,  lasting  day  and  night,  may  continue 
*  Bnt.  .][(',/.  Jour.,  vol.  ii.,  18SS. 


492  THE    MORIHD    BRAIN    IN    INSANITY. 

for  months  or  even  years  ere  a  fatal  termination  ensues.  The  subject 
is  a  perfect  automaton,  moves  only  when  pushed  along,  requires 
feeding  by  hand,  but  swallows  the  bolus  of  food  when  placed  in  his 
mouth,  and  lies  in  bed  torpid  and  motionless,  giving  utterance  to  no 
articulate  sound.  In  one  case — that  of  an  aged  demented  female,  in 
whom  the  framework,  muscles  and  integument,  testified  to  extreme 
atrophy — such  a  condition  was  induced  during  the  last  two  years  of 
her  life ;  but,  at  long  intervals,  evidence  of  nerve-instability  was 
forthcoming,  in  the  sudden,  unexpected  outburst  of  frantic  passion 
in  which  she  struggled,  kicked,  screamed  and  swore,  employing  a 
very  free  vocabulary  of  abusive  epithets ;  the  outburst  would  last 
for  but  a  minute,  when  the  profound  torpor  again  ensued.  For 
months  prior  to  her  death  she  remained  bed-ridden  and  during  the 
■whole  of  the  period,  except  when  roused  for  feeding,  in  a  state  of 
apparent  profound  sleep.  Feeding  had  to  be  pursued  with  care,  as 
she  would  often  neglect  swallowing  the  food  placed  in  her  mouth  to 
lapse  into  her  drowsy  state,  from  which  she  was  roused  only  by 
shaking  and  continuous  exhortation. 

In  another  typical  case,  the  patient  was  the  subject  of  general 
paralysis ;  in  this  form  of  disease,  the  symptoms  now  referred  to  and 
the  frontal  atrophy  associated  therewith  are  not  of  very  infrequent 
occurrence ;  the  condition  is  one  of  long  standing,  and  must  not,  of 
course,  be  confounded  with  the  temporary  stupor  of  the  congestive  and 
apoplectiform  seizures  incident  to  this  disease. 

That  extreme  atrophy  of  the  frontal  lobe  may  occur  in  congenital 
cerebral  affections  without  the  symptoms  here  alluded  to,  is  evident 
from  the  case  of  an  epileptic  lad  at  the  West  Riding  Asylum,  whose 
frontal  gyri  presented  attenuation  to  mere  riband-like  folds ;  and  in 
whom  restlessness  predominated.  Yet,  in  his  case,  intelligence  was 
so  far  extinct,  that  he  showed  no  appreciative  recognition  of  any 
objects  around  him,  and  could  not  be  taught  to  feed  or  clothe  himself, 
or  attend  to  any  of  his  bodily  wants ;  he  mechanically  sucked  every- 
thing placed  in  his  hands ;  could  just  utter  imperfectly  his  own 
christian  name.  All  his  senses  were  intact.  Goltz,  in  his  removal  of 
the  frontal  region  in  dogs,  noted  that  the  senses  were  intact;  there 
was  great  irritability  and  restlessness ;  they  had  a  stupid,  fixed 
expression  of  eye ;  in  following  a  bone  thrown  before  them  they 
apparently  forgot  their  object  and  passed  it  by.* 

Horsley  and  Schafer  observed  temporary  Stupidity  in  monkeys, 
from  whom  the  prefrontal  lobes  had  been  removed  ;  but  more  to  our 
point  at  present  are  the  observations  of  Professor  Ferrier,  who,  upon 

*  PJluger\s  Archiv.,  Bd.  xxxiv. ,  1884. 


THE    BRAIN    AND    ITS    MEMBRANES    IN    GENERAL    PARALYSLS.  493 

removal  of  the   prefrontal   region  in   monkeys,    noted    the  following 
facts — to  quote  his  own  words  : — 

"  Instead  of,  as  before,  being  actively  interested  in  their  surroundings,  and 
curiously  prying  into  all  that  came  within  the  field  of  their  observation,  they 
remained  apathetic  or  dull,  or  dozed  off  to  sleep,  responding  only  to  the  sensations 
or  impressions  of  the  moment,  or  varying  their  listlessness  with  restless  and  pur- 
poseless wanderings  to  and  fro.  While  not  absolutely  demented,  they  had  lost, 
to  all  ai^pearance,  the  faculty  of  attentive  and  intelligent  observation."  * 

It  is  impossible,  upon  reading  this  description,  not  to  be  struck  by 
the  remarkable  similarity  presented,  in  the  mental  deterioration  of 
the  patients  to  whom  we  have  alluded,  to  the  animals  in  whom  the 
prefrontal  lobes  had  been  removed. 


PATHOLOGICAL  ANATOMY  OF  GENERAL  PARALYSIS. 

Contents. — the  Brain  and  its  Membranes: — Early  implication  of  Vascular  Tissues — 
Vital  and  Mechanical  Effects — Effects  on  Lymph-Connective  System — Intra- 
cellular Digestion— i?o?e  of  Phagocytes,  or  Scavenger-Cells— Character  of 
Scavenger-Element— Its  Vascular  Process — Fuscous  Degeneration  of  Kerve- 
Cells — Three  Stages  of  Morbid  Evolution: — Inflammatory  Engorgement— Impli- 
cation of  Pia-Arachnoid — Nuclear  Proliferation  on  Adventitia— Paralysis  of 
Arterial  Tunics — Diapedesis— Exudation — Haemorrhagic  Transudations — Arach- 
noid Hajmorrhage— Second  Stage  :— Hypertrophy  of  Lymph-Connective  System 
—Fuscous  Change  and  Removal  of  Nerve-Cells — Nature  of  the  Destructive 
Process — Early  Implication  of  Apex  Process — Third  Stage  :— Fibrillation  and 
Atrophy.  The  Spinal  Cord: — Spinal  Cases  in  Four  Groups — Evolution  of  Pseudo- 
Tabetic  and  Spastic  Paraplegic  Forms  —  Angio-Neuroses  —  Pathogenesis  of 
Transient  Tabetic  Forms — Changes  in  Vascular,  Connective,  and  Nervous  Ele- 
ments— System-Implication  of  Lateral  Columns — Secondary  to  Cortical  Lesions 
— Respects  Systematic  Barrier— Chronic  Parenchymatous  Myelitis— Dependent 
on  Gradual  Degeneration  of  Cortical  Cells— Amyotrophic  Form— Degeneration 
of  Cornual  Elements  in  Cervical  Associated  with  Descending  Lateral  Sclerosis 
in  Dorsi-Lumbar  Regions — Combined  System-Implication  of  Cohmins — Pseudo- 
Tabetic  Forms— Ataxic  Tabes— Loss  of  KneeJerk— Anorexia— Flashing  Pains 
and  Sensory  Symptoms— Genuine  Tabetic  Forms  in  General  Paralysis. 

The  Brain  and.  its  MemtoraneS. — The  earliest  indication  of  morbid 
change  is  certainly  presented  by  the  vasculap  tiSSUeS  ;  turgescence 
of  the  vessels  of  the  pia,  great  distension  and  engorgement  of  the 
cortical  arterioles,  are  seen  as  the  apparent  result  of  an  irritative 
process  in  their  tissues.  The  perivascular  lymph-channels  are  the 
site  of  a  nuclear  proliferation  and  segmentation  of  protoplasm,  often 
so  enormous  as  to  entirely  conceal  the  enclosed  vessel  from  view. 
Certain  methods  of  staining  and  preparing  nerve-tissue  are  peculiarly 
adapted  for  exhibiting  this  change  in  the  early  stage  of  general  par- 
alysis ;  and  it  may  be  stated  that  the  usual  chrome  methods  are  so 

*  Functions  of  the  Brain,  2nd  edit.,  p.  40L 


494        PATHOLOGICAL  ANATOMY  OF  GENKRAL  PARALYSIS. 

prejudicial  to  the  morbid  texture,  that  those  who  exclusively  adopt 
them  must  have  failed,  as  a  natural  result,  to  appreciate  the  true 
nature  of  the  morbid  change  produced,  and  the  very  serious  impli- 
cation of  the  vascular  tracts  which  ensues.  This  development  of 
nuclei  along  the  lymph-sheath  embracing  the  vessel  must  be  regarded 
as  a  genuine  inflammatory  condition ;  accompanying  it,  we  observe 
the  usual  signs  of  an  inflammatory  process,  a  transudation  of  the  fluid 
contents  of  the  vessels  into  the  lymph-channel  and  tissue  beyond — 
a  diapedesis;  or  an  escape  of  amoeboid  leucocytes  from  within  the  vessel 
through  its  coats,  and  collections  of  haematoidine  crystals,  frequently 
at  the  angular  bifurcation  of  the  vessels  or  between  it  and  the  peri- 
vascular sheath. 

The  results  of  this  inflammatory  process  are  very  damaging  to  the 
blood-vessel  itself;  changes  are  induced  of  a  vital  and  mechanical 
nature.  Vital,  in  so  far,  that  the  neighbouring  inflammatory  state  of 
the  sheath  appears  to  paralyse  the  tunica  muscularis  of  the  smaller 
arteries,  and  the  natural  elasticity  of  the  vessel  becomes  also  impaired  ; 
a  relaxation  ensuing  which  favours  in  a  high  degree  stasis  of  the  blood 
current,  aneurismal  distensions,  and,  on  further  mechanical  obstruction, 
rupture  of  the  vessel.  Mechanical,  in  so  far,  that  the  uniform  support 
of  the  adventitial  sheath  is  impaired  or  lost,  or  its  nuclear  accumu- 
lations encroach  on  the  lumen  of  the  vessel  and  compress  it ;  or  its 
transudation-contents  in  like  manner  (or  otherwise)  prejudicially  aff'ect 
the  other  tunics  of  the  vessel.  At  a  still  later  period  the  sheath  is  yet 
further  damaged  by  the  numerous  branching  processes  of  cells  exti'a- 
vascular  in  position,  which  play  so  important  a  role  in  the  morbid 
process,  and  to  which  we  must  now  direct  attention. 

In  this,  the  second  stage,  there  proceeds  a  remarkable  development 
of  the  lymph-connective  system  of  the  brain.  The  cells,  which 
are  usually  described  as  "glia  cells,"  or  what  we  have  in  our  anatomical 
section  alluded  to  as  the  "flask-shaped  elements"  of  the  neuroglia, 
undergo  a  wondrous  transformation,  the  real  significance  of  which  does 
not  appear  to  have  been  hitherto  appreciated.  We  will  first  describe 
these  elements  in  their  pathological  developments  ;  and,  subsequently, 
allude  to  the  important  role  they  play  in  the  morbid  evolution  of  this 
disease.*     As  before  stated,  these  elements  ai'e  small  flask-shaped  cells 

*  Intra-cellular  digestion  is  now  an  established  pathological  fact,  and  the 
researches  of  MetschnikofF  have  extended  largely  the  rdle  of  certain  cellular 
organisms  in  the  elimination  of  morbid  material.  The  term  phagocyte^,  which  he 
employs  for  those  large  cells  active  in  the  removal  of  effete  material  in  the  frog 
and  other  cold-blooded  animals,  we  have  employed  when  referring  to  the  spider- 
cell  ;  but  we  prefer  the  term  scaverKjer-cell  for  those  fixed  tissue-organisms  which, 
as  we  have  seen,  have  an  active  physiological  and  pathological  rOle.  See 
Metschnikoff's  Original  Articles,  Virchoiv's  Archiv.,  vols,  xcvi.,  xcvii. 


LYMPH-CONNECTIVE    SYSTEM,  495 

with  a  comparativoly  large  nucleus  at  their  greater  extremity,  which 
latter  staius  but  faintly  with  aniline-black,  whilst  the  protoplasm  of 
the  cell  itself  remains  unstained,  and  so  delicate  as  to  be  recognised 
with  difficulty  in  healthy  states.     Each  has  a  connection  by  a  delicate 
process  with  a  neighbouring  blood-vessel,  and,  in  frozen  sections  fresh 
examined,  exhibits  several  i-adiate  branches  so  fragile,  and  excessively 
delicate,  as  to  be  only  seen  after  a  keen   search,   since  they  remain 
wholly  unstained  by  reagents  {Fl.  xviii.).     In  the  morbid  change  to 
which  we  now  allude,  these  flask-shaped  cells  enlarge  very  considerably 
into  great  amoeboid-like  masses  of  protoplasm,  often  exhibiting  sub- 
division of  the  nucleus  ;  and,  what  is  of  great  import,  their  protoplasm 
now  stains  deeply  with  aniline,  although  not  so  intensely  as  do  their 
nuclei.      From  this  extraordinary  cell  of  protean  form  radiate  on  all 
sides  numerous  branching  fibrils,    forming  an  intricate  and  delicate 
network  around  it  as  a  centre,  all  of  which  branches,  even  to  their 
most  delicate  subdivisions,  are  readily  stained  by  the  same  reac^ent. 
These  cells  have  been  termed  Deiter's  cells  :  they  are  all  characterised 
by  the  presence  of  a  vascular  process ;    but  well-prepared  specimens 
show  us  not   one,  but  often  several,  such   processes  distinguished  by 
their   greater   diameter,   their   deep  staining,   and    their   termination 
in    a  nucleated-mass  of   protoplasm  upon  the  walls  of  a  blood-vessel 
{PI.  xviii.).     The  students'  attention  should  be  drawn  to  the  fact  that 
in  healthy  states  of  the  cortex  these  peculiar  neuroglia  elements  may 
be  readily  distinguished  from  the  nerve-cells,  apart  from  their  contour, 
by  the  fact  that  their  nucleus  alone  stains  faintly  with  aniline,  whilst 
both  protoplasm  of  cell  and  nucleus  of  the  nerve-elements  stain  deeply  ; 
whereas,  in  the  diseased  state  to  which  we  allude  the  morbid  elements 
act  like  nerve-cells,  both  nucleus  and  cell-protoplasm,  as  well  as  ulti- 
mate fibrils,  become  deeply  tinged  by  the  dye,  so  that,  in  some  cases, 
they  do  not  look  unlike  nerve- cells ;  and  a  few  may  even  be  mistaken 
for  such,  until   the   "vascular  process"  is  detected.       This  difierent 
reaction  in  the  diseased  state  is  doubtless  due  to  the  increased  and 
unnatural  vitality  *    of  these    protoplasmic    masses.       These    lymph- 
connective  elements   (normally  spread  as  free  cells,  except  for   their 
vascular   branch,  throughout  the  neuroglia-framework  of  the   brain) 
multiply  by  nuclear  division  and  segmentation  of  the  cell-mass  until 
their  numbers  are  so  prodigious  as  to  rival  the  densest  groupings  of 
nerve-elements  in  the  same  region  (PI.  xvii. ;  PI.  xvi.,  fy.  2).     Their 
normal  off"-shoot  from  the  parent-vessel,  or  its  sheath,  explains  their 
more  dense  distribution  on  either  side  of  the  vascular  channels ;  but 

*  Even  nerve-cells  in  certain  diseased  states  stain  7norc  intensely  than  in  health 
—e.g.,  early  stage  of  fuscous  degeneration— but  subsequently  the  reaction  becomes 
progressively  less  intense. 


496  PATIlOLOr.ICAL    ANATOMY    OF    GENERAL    PARALYSIS. 

they  may  jtermeate  every  tract  of  the  cortex,  from  the  peripheral 
zone  to  the  deepest  layer,  and  are,  moreover,  often  formed  deep  in 
the  medullated  structure  of  the  brain. 

Whenever  a  branch  forms  a  new  connection  with  a  blood-vessel, 
at  its  junction  with  the  sheath  there  is  invariaVjly  found  a  nucleated 
mass  of  protoplasm,  often  undergoing  subdivision,  and  this  process  is 
specialised  by  its  greater  size  and  depth  of  staining;  the  other 
processes  are  much  finer  and  more  delicate,  take  a  more  tortuous 
course,  and  branch  into  numerous  still  finer  ramifications  (Fl.  xviii.). 
Co-eval  with  this  morbid  transformation,  we  find  the  nerve-cells  present 
indubitable  evidence  of  a  degenerative  process  (PI.  xy'i.,  Jig.  1 ;  PL  xviii.). 
The  morbid  condition  of  the  cell  has  itself  been  described  by  some 
authors  as  inflammatory  in  its  intrinsic  nature  (Mierzejewski) ;  Vjut, 
when  carefully  studied,  we  wholly  fail  to  recognise  an  inflammatory 
condition,  we  see  but  the  evidence  of  a  true  degeneration  due  to  acute 
nutritional  anomalies,  and  fail  to  observe  any  notable  difi"erence  be- 
tween the  changes  through  which  these  cells  pass,  and  those  of  the 
cortex  in  senile  atrophy,  except  in  the  greater  tendency  to  a  true 
steatosis  in  the  latter  state  ;  and  still  less  do  we  perceive  the  dis- 
tinction from  what  is  observed  in  the  "  fusCOUS  "  chang'e  of  the  large 
cortical  cells  of  the  epileptic's  brain  (PL  xiv.). 

Where  the  cortex  is  extensively  invaded  by  the  abundance  of  lymph- 
connective  cells,  the  nerve-cells  will  be  found  to  present  every  stage  of 
degenerative  transformation  from  an  incipient  change  in  molecular 
consistence  and  coarseness  to  a  broken-down  residue  recognised  only 
as  a  faintly  pigmented  patch,  scarcely  preserving  its  outline  as  a 
cellular  structure  (PL  xv.,Jig.  3).  What  is  highly  important  for  us  to 
note  is  the  connection  betwixt  such  cells  and  the  neuroglia-elements 
just  described.  The  processes  of  these  morbid  elements  apply  them- 
selves to  the  nerve-cells,  surround  and  embrace  them  closely ;  whilst 
the  latter  are  often  overlaid  by  one  or  more  of  these  spider-like  bodies, 
still  maintaining  their  connection  by  a  long  straight  jrrocess  with  a 
distant  capillary  (PL  xvii.). 

Occasionally,  the  branches  appear  directly  connected  with  the  nerve- 
cell,  and  at  their  junction  a  minute  nuclear-like  mass,  more  deeply 
stained,  is  seen.  Wherever  we  find  the  nerve-elements  much  invaded 
by  their  strangely  transformed  congeners,  there  we  observe  advanced 
degeneration  of  the  cell,  to  describe  which  in  detail  would  be  to  repeat 
the  description  already  given  of  pigmentary  or  fuscous  decay  (p.  473). 
It  may  be  stated  here,  however,  that  the  apical  process  appears  to 
sufier  at  an  early  stage  of  the  disease,  and  disappears  often  before  the 
cell  itself  is  very  gravely  implicated. 

As  the  nerve-cells  undergo  more  and  more  serious  disorganisation 


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STAGES    OP    MORBID    EVOLUTION.  497 

and  dwindle  away,  so  these  elements  of  the  neuroglia  multiply  and 
throw  out  their  protoplasmic  extensions  in  all  directions  around,  tie 
down  blood-vessels,  draw  the  perivascular  sheaths  by  their  contraction 
out  of  their  normal  course  so  that  they  become  (as  represented  in  the 
figure,  Fl.  xviii.)  pulled  in  this  or  that  direction  into  innumerable 
angular  or  funnel-like  extensions  by  the  attached  processes  of  these 
cells  ;  the  vessels  themselves  become  contorted,  and  drawn  from  their 
normal  direction. 

Then  a  further  change  ensues,  the  cellular  elements  appear  to  reach 
a  limit  to  their  morbid  activity,  and  expend  their  remaining  vitality 
in  a  dense  fibrillation.  The  protoplasm  of  the  cell  dwindles  down 
as  these  meshworks  of  fibres  form  around  it,  and  the  nucleus  alone 
remains  as  a  sort  of  nodal  point  from  which  this  fibrillated  mesh 
radiates  as  from  a  centre,  its  branches  interlacing  most  intimately.*" 
This  stage  of  dense  fibrillation  and  disappearance  of  the  cell-protoplasm 
is  the  third  Stag'e  in  the  morbid  evolution  of  general  paralysis. 

To  recapitulate,  we  have  three  well-marked  steps  thus  defined 
whereby  we  may  trace  the  morbid  implication  of  the  cortex. 

1.  A  stage  of  inflammatory  change  in  the  tunica  adventitia  with 
excessive  nuclear  proliferation,  profound  changes  in  the  vascular 
channels,  and  trophic  changes  induced  in  the  tissues  around. 

2.  A  stage  of  extraordinary  development  of  the  lymph-connective 
system  of  the  brain,  with  a  parallel  degeneration  and  disappearance 
of  nerve-elements,  and  the  axis-cylinders  of  which  are  denuded. 

3.  A  stage  of  general  fibrillation  with  shrinking,  and  extreme 
atrophy  of  the  pax^ts  involved. 

We  may  now  proceed  more  fully  to  enquire  into  the  indications 
afforded  us  by  the  morbid  changes  characterising  the  above  stadia. 

Stag'e  of  Inflammatory  Eng-orgement. — It  is  in  the  vessels  of 

the  2^i<^  that  lesions  are  earliest  witnessed,  and  the  lymphatic  sheath  is 
that  in  which  the  inflammatory  change  originates.  Here  it  is  that,  in 
the  earliest  stages  of  the  disease  observed  in  the  brain  of  a  general 
paralytic,  the  initial  vascular  derangements  are  first  to  be  noted;  and 
cases  proving  fatal  at  an  early  stage,  through  the  agency  of  any  inter- 
current affection,  may  exhibit  (beyond  a  slight  general  cloudiness  of  the 
arachnoid  along  the  course  of  the  vessels  in  the  fronto-parietal  regions, 
and  a  very  slight  increase  in  the  toughness  of  the  membrane)  no  other 
naked-eye  evidence  of  disease.  The  membranes  may  be  slightly  more 
difficult  of  removal  than  in  health,  but  show  no  genuine  adhesion  to 
the  subjacent  cortex.     Yet  sections  of  cortex  examined  microscopically 

*  Such  isolated  nodules  of  dense  fibrillated  tissue  of  almost  microscopic  dimen- 
sions occasionally  occur  in  the  cerebellum.  Their  import  has  not  to  our  knowledge 
been  previously  recognised. 

32 


498         PATHOLOGICAL  ANATOMY  OP  GENERAL  PARALYSIS. 

nil  show  a  notable  increase  in  the  nucleated  protoplasmic  cells  of  the 
adventitia  of  the  vessels  of  the  pia,  which  vessels  are  also  large,  dis- 
tended, and  often  tortuous;  together  with  a  general,  though  slight, 
proliferation  of  the  most  superficial  flask-shaped  cells  of  the  peri- 
pheral zone  of  the  cortex,  and  the  vessels  of  the  intima  pise  resting 
upon  it.  From  these  cells  of  the  pia  long  delicate  processes  are  sent 
out  extending  deeply  down  into  this  layer;  and,  in  fact,  simulating  in 
this  early  stage  an  appearance  often  found  normally  in  the  cortex  of 
certain  domesticated  animals  (the  sheep,  pig,  rabbit,  &c.).  That  these 
changes  commence  in  the  vascular  supply  of  the  pia-arachnoid, 
gradually  extend  into  the  cortex,  and  eventually  penetrate  its  deepest 
layers,  numerous  examinations  have  established  beyond  doubt. 

In  a  further-advanced  stage  of  this  disease  the  soft  membranes 
become  far  more  gravely  implicated.  The  nuclear  proliferation  around 
the  vessels  of  the  pia,  their  distension  and  engorgement  (from  paralysis 
of  the  vital  contractility  of  the  muscular  coat)  lead  to  a  very  free 
exudation  into  the  meshes  of  the  pia.  The  connective  trabeculse  lying 
between  the  intima  pia  and  arachnoid  (which  are  so  especially  loose 
and  plentiful  within  the  sulci  separating  the  convolutions)  become 
saturated  with  a  fluid  exudate,  present  a  swollen  and  gelatiniform 
aspect  to  the  naked  eye,  streaked  with  opaque  lines,  or  assume  a  patchy, 
or  a  general  and  uniformly-difiused  opalescence ;  whilst  to  histological 
examination  of  sections  they  reveal  beautifully-disposed  mesliworks  of 
connective  fibrils,  rich  in  cells,  and  permeating  in  every  direction  the 
subarachnoid  space.  Into  this  space  exude  the  cellular  and  fluid 
products  of  the  inflammatory  sheath.  This  tendency  to  the  accumula- 
tion of  exudate  in  the  subarachnoid  lymph-tissue  receives  a  marked 
increment  at  a  later  stage  of  the  disease;  foi',  when  atrophic  changes 
occur  in  the  cortex  as  the  result  of  impaired  nutrition  and  degeneration 
of  nerve-elements,  a  great  compensatory  serosity  of  this  region  is 
established,  and  the  membranes  become  fairly  water-logged.  The 
atrophy,  which  is  the  result  of  a  genuine  sclerous  change  in  the 
cortex,  is  necessarily  more  marked  in  the  sulci  than  over  the  summits 
of  the  gyri,  the  area  of  cortical  surface  involved  in  the  one  case  being 
far  greater  than  in  the  other,  and,  in  consequence  thereof,  the  gyri 
become  narroived  and  attenuated — the  thinning  of  the  cortical  layers 
being  the  most  marked  feature. 

The  vessels  in  the  pia  lose  the  normal  support  received  from  the 
opposed  gyri,  and,  as  more  compensatory  eff"usion  occurs  to  fill  up  the 
space  left  by  the  receding  brain  structure,  so  the  natural  support 
received  by  their  walls  becomes  lessened,  and  in  the  diseased  state  of 
their  parietes  there  becomes  established  a  strong  tendency  to  hsemor- 
rhagic  transudation,  or   to  actual    rupture   and    haemorrhage.      Such 


STAGE    OF    INFLAMMATORY    ENGORGEMENT,  499 

haemorrhages  may  be  slight  and  merely  punctiform,  and  are  frequently 
observed  ;  or  blood  may  be  transfused  into  the  subarachnoid  space  and 
a  fibrinous  coagiilum  form  upon  its  meshwork ;  or,  as  we  often  see, 
a  film  of  blood  may  be  exuded  upon  the  epicerebral  surface,  between 
the  pia  and  cortex ;  or,  lastly,  the  delicate  and  perforated   arachnoid 
may   permit   an   extravasation    on  to  its  outer  surface,  so   that   the 
subdural  space  may  thus  become  the  site  of  a  more  or  less  extensive 
hemorrhage.      The  latter,   or   so-called    mening"eal    hsemOPPha^e, 
may  be  a  mere  delicate  film  of  blood,  or  a  simple  rusty  staining  of  the 
arachnoid  surface,  or  a  thick  coagulum  of  blood  extending  over  the 
greater  part  of  one  or  both  hemispheres ;  or  a  coagulum  within  a  firm 
fibrinous  or  organising   investment  completely  encysted ;  or,  again,  a 
thin,  but  tough,  glutinous  or  fibrinous  pellicle,  slightly  rust^stained, 
may  be  peeled  ofi"  the  surface  of  the  dura,  forming  one  or  other  of  the 
varieties  of  the  so-called  arachnoid  cysts.     These  encysted  haemorrhages 
(which    are    by    no    means    peculiar    to   general    paralysis,    although 
frequently  associated  with   this  disease)  appear  to  be  due,  in  these 
cases  at  least,  to  an  initial  extravasation  caused  by  the  rupture  of  a 
diseased  vessel  in  the  pia-arachnoid,  and  to  the  subsequent  rupture  of 
newly-formed  vessels  within  the  organising  clot.     In  none  of  these  cases 
does    it   appear  to  us  to   have  a  direct   inflamviatory  origin   in   the 
membranes.     Beyond  these  extravasations  and  infiltrations  of  blood, 
which    invariably  occur   during  an   advanced   atrophic    stage  of  the 
disease,  we  find  similar  conditions  established  within  the  cortex  itself 
Here,  also,  the  blood-vessels  lose  the  normal  support  given  them   in 
health  by  the  approximation  of  the  perivascular  walls,  which  permit 
of  a  limited,  but  a  definitely-restricted,  expansion.     In  atrophy  of  the 
cortex,   however,   these   channels    become    enormously    enlarged    and 
filled  also  with  exudate  from  the  contained  vessels ;  this  distension  of 
the  perivascular  channels  favours  the  aneurysmal  dilatations  already 
alluded  to,  and  the  eventual  rupture  or  transudation  of  the  contents 
of  the  blood-vessels   into   the   surrounding   space    and    neighbouring 
tissue.     Hence   we  get,   in  all  such   cases,   evidence   of  extravasated 
blood    in   the    form   of  hsematoidine  crystals,   which    often    occur   in 
aggregated   heaps,   especially  in   the   neighbourhood   of  degenerating 
nerve-cells.     It  would  appear  that  the  natural  subsidence  of  compen- 
satory fluid   into   the  sulci,   and  the  much  greater   recession   of  the 
atrophic  cortex  allowed  for  by  the  special  position  of  the  walls  of  the 
gyri,  is   unfavourable  to  the  formation  of  adhesions  ;  for  it  is  a  fact 
that  such  morbid  adhesions  in  general  paralysis  are  almost  strictly 
limited  to  the  summits  of  the  gyri,  where  the  pia-arachnoid  is  in  close 
contact  and  does  not  permit  of  the  accumulation  of  serosity  to  nearly 
the  same  extent  as  in  the  sulci.     As  the  inflammatory  state  of  the 


500        PATHOLOGICAL  ANATOMY  OF  GENEKAL  PARALYSIS. 

lyini)hatic  sheath  of  the  vessels  extends  to  the  deeper  layers  of  the 
cortex,  other  grave  disturbances  necessarily  ensue ;  and  this  leads  us 
to  the  second  stage  of  the  disease,  which  is  characterised  by  the 
extraordinary  development  of  the  lymph-connective  system  of  the 
brain. 

Second  Stag'e. — The  implication  of  the  perivascular  lymph-channels 
by  the  enormous  production  of  protoplasmic  masses  on  their  walls,  and 
the  blocking  of  their  channels  and  impairment  of  the  vascular  tissues, 
directly  affect  the  nutrition  of  the  nerve-cells.  A  granular  change 
ill  their  protoplasm  ensues,  and  fusCOUS  deg"eneration  of  theii- 
contents  leads  to  their  ultimately  breaking-down  into  a  fine  molecular 
mass  of  debris.  This,  together  with  inflammatory  exudates  from  the 
vessels,  must  be  removed ;  but  the  lymph-channels  are  not  in  such  a 
condition  as  to  ensure  this  removal  of  effete  material.  It  is  at  this 
juncture  that  the  supplementary  lymph-connective  element  comes  into 
play.  In  the  normal  state,  maintaining  its  connection  with  the 
vascular  walls  by  its  Deiter's  process,  it  either,  by  circulation  of 
protoplasm  or  by  contraction  of  the  latter,  removes  such  effete  material 
from  the  cortex.  Now,  however,  these  organisms  rapidly  increase  in 
size  and  numbers,  forming  large  amoeboid  masses  of  protoplasm,  which 
apply  themselves  to  all  the  degenerative  elements  around,  and  by  a 
process  of  intussusception  remove  such  particles  into  their  interior. 
For  long,  these  spider-like  cells,  or  Deiter's  cells  as  they  have  been 
termed,  have  been  recognised  by  sevei'al  authorities  in  the  coi'tex  of 
the  general  paralytic,  and  veiy  varying  and  conflicting  statements 
have  been  made  respecting  them ;  by  some,  they  were  regarded  as 
metamorphosed  leucocytes  wandering  from  the  blood-vessels ;  by 
others,  as  a  simple  px'oliferating  connective,  which  by  its  pressure  and 
strangulation  destroyed  the  neighbouring  nerve-tissues ;  others,  again, 
saw  in  them  no  special  connection  with  general  paralysis,  since  they 
have  been  recognised  in  various  diseased  states  of  the  brain.  It  is 
true  that  these  organisms  are  met  with  in  other  affections  of  the 
nervous-system,  but  simply  because  they  play  a  most  important  role 
in  the  pathology  of  nervous  diseases,  and  it  is  only  when  their  real 
functional  endowments  are  perceived  that  we  recognise  their  important 
significance  in  the  cortical  lesions  of  general  pai'alysis. 

The  failure  of  the  usual  lymphatic  tracts  to  remove  efl'ete  matter 
from  the  brain  reacts  by  calling  forth  an  increased  functional  activity 
in  these  lymph-connective  appendices  in  the  neuroglia,  a  true  functional 
hypertrophy  ensues,  and  these  spider-like  elements  apply  themselves 
to  the  task.  They  become  the  "phagocytes"  or  scavewr/ers  o/^Ae  tissue; 
live,  thrive  and  multiply  upon  the  degenerating  protoplasmic  masses 
of  nerve-cells  and  their  extensions,  and  all  effete  material  lying  in 


STAGES    OP    CELL    DEGENERATION    AND  FIBRILLATION.  501 

their  neighbourhood  is  ultimately  appropriated  to  their  use.  These 
active  scavengers  are  also  destructive  of  the  living  tissues;  they  affix 
tlieir  sucker-like  processes  to  any  portion  of  their  structure,  and  at  the 
point  of  juncture  we  invariably  see  a  small  speck  of  active  protoplasm 
containing  a  nucleus,  probably  in  process  of  subdivision.  Occasionally, 
several  of  these  active  elements  are  seen  completely  covering  a  large 
nerve-cell,  which  is  in  an  advanced  stage  of  decay,  or  scarcely  visible, 
forming  a  mere  pigmented  molecular  groundwork.  They  are  usually 
noted  in  great  abundance  in  the  deeper  half  of  the  peripheral  or 
outermost  layer  of  the  cortex,  and,  being  unmixed  with  nerve-cells,  are 
here  peculiarly  clear  and  defined.  At  this  site  their  destructive  agency 
makes  itself  felt  upon  the  medullated  nerve-fibres,  which  at  this  depth 
run  parallel  to  the  surface  of  the  cortex  as  continuations  of  the  apical 
processes  of  the  cells  of  the  lower  layers.  These,  therefore,  are  the 
first  nervous  structures  to  be  involved,  and  the  apical  processes  of  the 
pyramids  are  the  first  to  undergo  degenerative  change. 

Third  Stag'e. — Like  all  actively-growing  elements  these  also  have 
only  a  limited  existence  in  this  condition  of  morbidly-exaggerated 
function.  The  cells  throw  out  innumerable  fine  processes ;  and  as  the 
fibrillar  meshworks  increase  so  the  cell-protoplasm,  at  whose  expense 
they  appear  to  be  formed,  dwindles  down  and  eventually  disappears. 
Hence  we  have  here  a  veritable  substitution  of  fibrillar  connective 
formed  out  of  the  effete  material  afforded  by  the  atrophic  nerve-tissue, 
a  genuine  degradation  of  tissue.  The  process  does  not  appear  to  us 
to  be  at  all  akin  to  the  destructive  influence  of  a  compression  from 
sclerous  invasion ;  but  rather  that  the  presence  of  the  sclerous  element 
is  explained  by  its  production  out  of  already-degenerated  nerve- 
elements. 

The  Spinal  Cord. — The  spinal  symptoms  associated  with  the  cere- 
bral disturbances  of  general  paralysis  have  long  been  a  subject  of 
intense  interest  to  the  pathologist;  and  much  diversity  of  opinion 
exists  relative  thereto,  less  so,  perhaps,  respecting  the  intrinsic  naizire 
of  the  morbid  change,  as  the  mode  of  implication  of  the  spinal 
tissue-elements  and  the  initiator^/  conditions  upon  which  the  lesion 
depends.  As  is  well  known,  the  spinal  cord  is  by  no  means  uniformly 
implicated  in  all  cases  of  general  paralysis ;  nor  is  the  selected  site  of 
morbid  change  a  constant  feature.  A  large  majority  of  cases  of 
general  paralysis  pass  through  the  various  stages  of  the  disease  with- 
out any  notable  spinal  symptoms,  apart  from  those  due  to  implication 
of  the  bulbar  nerve-nuclei,  until  the  latest  epoch  of  the  affection  is 
reached ;  whilst  in  others,  from  the  very  outset  the  spinal  symptoms 
are  the  most  prominent  feature  of  the  case.  In  other  cases,  again,  the 
spinal    symptoms  appear  to   bear  a  definite  relation   to  the   various 


502  PATHOLOfJlCAL    ANATOMY  OF    <;RNEKAL    PAllALYSIS. 

stages  of  cerebral  disturbance,  and  vary  in  their  nature  pari  lyassu 
with  the  latter.  Thus  we  may  be  permitted  to  group  cases  usually 
encountered  into  four  arbitrary  divisions. 

(1)  In  the  majority  of  cases,  we  have  as  the  only  evidence  of  spinal 
implication,  a  somewhat  general  diminution  of  cutaneous  sensibility, 
associated  with  a  sluggish  or  greatly-diminished  knee-jerk  ;  alternating 
later  on  with  (or  supplanted  by)  increased  knee-jerk,  usually  as  the 
direct  sequel  to  a  convulsive  or  apoplectiform  seizure.  Later  on,  in 
the  disease,  2^(^'>'^tic  symptoms  may  predominate,  and  contractions  be 
established ;  but  these  follow  in  the  wake  of  pronounced  cerebral 
disturbances  (convulsions,  &c.),  and  appear,  in  fact,  to  be  initiated 
thereby  ;  whilst  the  cerebral  implication  throughout  has  been  all  along 
the  more  emphasised. 

(2)  Here,  there  is  a  second  group  comprising  from  the  very  onset 
notable  tabetic  symjytoms,  the  cerebral  often  so  greatly  in  abeyance  as 
to  arouse  the  doubt  whether  we  are  not  here  engaged  with  a  genuine 
tabes  dorsalis  of  local  spinal  origin.  The  disturbance  of  sensation,  the 
abolition  of  the  deep  reflexes,  the  ataxic  gait,  are  all  so  prominent  that 
we  are  apt  to  attribute  such  symptoms  to  a  primary  implication  of  the 
cord  itself.  And  yet,  in  this  tabetic  form  of  general  paralysis,  we  most 
usually  witness  complete  subsidence  of  the  special  spinal  symptoms, 
the  tabetic  gait  passes  oft"  the  knee-jerk  returns,  and  then  the  full 
development  of  the  cei-ebral  symptoms  is  established ;  or,  what  is  not 
infrequent,   the   sensory   implication    of  the    cord  becomes  a  motory 

afiection  and  spastic  paraplegia  replaces  the  ansBsthesia  and 
ataxy. 

(3)  In  yet  another  series  of  cases,  the  viotor  sjmial  anomalies  are 
from  the  first  a  most  notable  feature ;  and  symptoms  indicating 
a  symmetrical  descending  sclerosis  of  the  lateral  columns  are  early 
apparent,  usually  as  the  sequel  of  convulsive  seizures,  a  mode  of 
implication  which  appears  to  us  of  special  frequency  in  general 
paralysis  attecting  those  subjects  who  are  addicted  to  alcoholic  indul- 
gence. 

(4)  Lastly,  there  are  those  cases  where  no  spinal  symptoms  whatever 
are  noticed,  the  derangements  being  cerebral  throughout  (13-6  per 
cent.). 

In  explaining  the  features  comprised  under  these  arbitrarily-con- 
stituted groups,  there  has  been  a  tendency  to  regard  the  later-evolved 
cerebral  derangements  of  typical  general  paralysis  established  in  a 
well-marked  tabetic  case,  as  due  to  an  ascending  change — i.e.,  to  pro- 
pagation by  direct  continuity  of  diseased  tissue ;  thus  making  a 
system-disease  of  the  spiual  cord  the  originating  factor  of  the  subse- 
quent cortical  lesions  of  general  paralysis. 


\v.. 


PATHOGENESIS    OF    SPINAL    IMPLICATION.  503 

And,  in  like  manner,  the  subsequent  establishment  of  motor  spinal 
symptoms  {spastic  paraj)le(jia)  has  been  regarded  as  a  direct  transference 
of  morbid  implication  across  from  sensory  to  motor  columns  of  the 
cord,  or  to  a  descending  lateral  sclerosis  having  direct  continuity  with 
cortical  lesions.  It  appears  to  us  that  there  is  little  evidence  in  favour 
of  such  views,  which  would  seem  to  originate  in  too  servile  an  atten- 
tion to  the  great  law  enunciated  by  Waller.  The  Wallerian  degener- 
ations do  account  for  much  in  the  pathological  reductions  of  general 
paralysis;  yet  it  appears  to  us  to  be  much  strained  by  efforts  to 
establish  its  role  when,  after  repeated  attempts  made  to  trace  such 
degenerative  continuity  of  tissue,  the  best  observers  have  invariably 
been  foiled.  It  is  a  notable  fact  that,  despite  frequent  and  most 
careful  examinations  of  the  spinal  lesions  of  general  paralysis,  we  yet 
fail  to  trace  the  continuity  of  descending  changes  of  the  lateral 
columns  of  the  cord  with  the  tegmental  structures  of  the  pons. 
We  are  apt  in  paying  too  strict  attention  to  the  operation  of  this 
important  law  to  overlook  the  transfer  of  disease  to  distant  parts  of 
the  nervous  system  through  implication  of  higher  realms,  not  hy  direct 
continuity  of  diseased  tissue,  but  through  the  vasomotor  agency 
operative  upon  nervous  tracts  in  physiological  sympathy  with  their 
higher  centres. 

This,  it  would  seem,  is  illustrated  in  the  pathogenetic  history  of 
general  paralysis,  wherein  irritative  or  destructive  lesions  of  the  cortex 
cerebri  invariably  produce  change  in  the  nutrition  of  the  cord,  vary- 
ing in  its  site,  nature,  and  intensity  with  the  regions  of  the  cortex 
implicated.  Physiological  experimentation  teaches  us  that  vascular 
tonus  is  dependent  upon  the  vasomotor  centre,  or  rather  centres, 
within  the  medulla  ;  such  centres  maintaining  their  regulative  capacity 
even  upon  removal  of  the  hemispheres  in  animals  ;*  yet,  it  is  never- 
theless true  that  though  thus  independent  of  cerebral  innervation,  the 
latter  steps  in  and  inhibits  the  activity  of  these  centres  in  the  medulla, 
as  seen  in  the  electric  stimulation  of  the  cortex,  and,  again,  in  its 
agency  during  certain  emotional  disturbances,  as  shown  in  the  pallor 
of  fright  and  the  blush  of  shame.  So  also  in  pathological  conditions, 
the  ang"io-neurOSeS  (or  affections  of  the  blood-vessels  through 
deranged  nervous  agency)  form  a  class  of  diseases  which  may  implicate 
any  tissue  or  organ  in  the  body  ;  and  in  like  manner,  the  vascular 
supply  of  the  cord  and  medulla  may  undergo  derangement  through  the 
disturbing  influence  of  the  higher  cortical  centres.       We  incline    to 

*  Section  of  the  medulla  at  the  calamus  scriptorius  paralyses  the  greater  part  of 
the  vasomotor  nerves  of  the  body,  and  the  blood-pressure,  consequently,  falls 
throughout  the  whole  arterial  system.  Landois,  op.  cit. ;  see  also  Ferrier,  Functions 
of  the  Brain.     Burdon-Sanderson,  Handbook  of  the  Phyaiolog.  Lahorator>i. 


504        PATHOLOGICAL  ANATOMY  OF  GENERAL  PAUALYSIS. 

regard  the  primary  implication  of  the  cord  in  general  paralysis  as  in 
this  manner  produced — as  being  a  genuine  angio-neurosis.  Later  on,  the 
destructive  lesions  in  the  cortex,  together  with  the  irritative  process  in 
the  cord  and  medulla,  lead  to  a  general  rise  in  blood-pressure,  as  seen 
in  the  sphygmographic  tracings  in  advanced  subjects  (p.  429).  The 
engorgement  of  the  blood-vessels  of  the  posterior  columns  of  the  cord  is 
followed  by  transudation  through  their  walls,  and  the  lymphatic  func- 
tions are  stimulated  to  increased  activity.  Usually  the  latter  function 
sufl&ces  to  re-establish  the  balance,  and  the  tabetic  symptoms  at  first 
apparently  subside;  but  occasionally  they  persist,  and  then  we  meet  with 
a  true  degenerative  change  in  the  posterior  columns.  The  pressure  of  the 
engorged  vessels  in  the  sensory  tract  of  the  cord  is  the  essential  cause 
of  the  early  tabetic  symptoms  and  sensory  distui-bances  of  many  cases 
of-  general  paralysis ;  and  in  the  fact  that  this  is  often  a  transient 
state,  not  necessarily  leading  to  destructive  results  in  the  nerAe- 
elements,  we  find  an  explanation  of  the  subsidence  of  such  symptoms. 
We  must  not  be  understood  to  imply  that  the  changes  in  the  posterior 
columns  of  the  cord  in  those  cases  of  general  paralysis  characterised 
by  persistent  tabetic  symptoms  are  due  to  the  identical  lesion  found 
in  typical  tabes  dorsalis ;  we  have  not  here  an  ascending  sclerosis  of 
these  columns,  but  a  very  distinct  affection,  which  appears  to  commence 
generally  and  simultaneously  through  large  tracts  of  the  cord ;  in 
genuine  tabes  we  perceive  extensive  and  extreme  destruction  of  nerve- 
fibres,  whereas  in  the  pseudo-tabetic  general  paralytic  we  often  find 
the  nerve-fibres  little  (if  at  all)  implicated.  In  some  of  the  most 
extreme  cases  of  the  disease  yet  observed,  the  nerve-fibres  of  the 
posterior  column  were  of  fair  size  and  apparently  healthy. 

With  respect  to  the  lateral  columns  of  the  cord,  however,  the  case  is 
different ;  a  genuine  sclerosis  is  here  established,  which  results  in 
progressive  destruction  of  nerve-tissue,  and  which  (although  it  may 
originate  at  one  or  several  sites)  spreads  downwards  as  a  descending 
sclerosis  along  the  physiological  tracts  on  which  it  has  established 
itself.  Commencing,  we  opine,  as  an  angio-neurosis  in  a  territory 
directly  in  sympathy  with  implicated  cerebral  areas,  it  leads  to  much 
more  profound  lesions  than  are  found  in  the  posterior  columns  of  the 
cord. 

In  the  posterior  columns  of  the  cord  the  morbid  appearance 
presented  must  be  studied  in  respect  to  the  vascular,  connective,  and 
nerve-elements  respectively. 

VaseulaP  System.^ — Nearly  all  cases  present  an  apparent  increase 
in  the  number  of  the  vessels  of  the  posterior  columns.  The  appearance 
is,  however,  deceptive,  in  that  there  is  not  an  absolute  numerical 
increase  in  the  vessels  seen  in  transverse  section,  but  an  increase  in 


CHANGES    IN    VASCULAR   AND   CONNECTIVE    STRUCTURES.  505 

their  size,  due  to  long-continued  engorgement,  which  renders  them  a 
most  prominent  feature  in  the  sectional  fields.  Limited  to  certain 
divisions,  or  scattered  indiscriminately  over  the  whole  area  of  these 
columns  in  aniline  or  hseraatoxylin  preparations,  they  at  once  obtrude 
themselves  on  our  notice.  The  individual  vessels,  although  of  large 
size,  have  a  lumen  greatly  diminished  by  the  encroachment  of  their 
thickened  walls  ;  the  muscular  coat  of  the  smaller  vessels  is  distinctly 
hypertrophied,  presenting  the  appearance  which  has  been  so  well 
described  by  Dr.  Johnson  in  the  renal  vessels  in  chronic  Bright's 
disease.  In  other  respects,  the  vessel  appears  free  from  morbid 
change ;  the  lymphatic  channels  are  not  unduly  distended,  no  pro- 
liferation of  nuclei  is  observed,  and  no  other  evidence  of  inflammatory 
change  in  the  vessel's  tunics  or  exudates  from  its  channel,  such  as 
were  described  in  the  vessels  of  the  cortex.  The  change  appears  to  be 
one  of  simple  compensatory  hypertrophy  induced  by  the  engorged 
condition  of  these  vessels  demanding  increased  contraction  on  the  part 
of  the  arterial  muscle  to  carry  on  the  circulation  of  the  cord.  Just  as 
in  the  renal  vessels,  the  muscular  coat  hypertrophies  to  overcome  the 
languid  circulation  of  the  organ,  so  the  muscularis  of  the  rachidian 
arterioles  increases  with  the  engorgement  of  these  columns,  induced 
by  the  changes  occurring  in  the  cerebral  cortex. 

The  Connective  System. — The  stellate  cells  found  normally 
throughout  the  columns  of  the  cord,  and  which  are  the  representatives 
of  the  delicate  neuroglia-elements  spoken  of  as  the  flask-shaped  bodies 
of  the  cortex  cerebri,  do  not,  in  the  healthy  cord,  form  so  prominent  a 
feature  in  transverse  sections.  In  diseased  states,  however,  they  not 
only  enlarge,  but  multiply  greatly,  and  their  proliferation  as  "  Deiter's 
cells "  is  a  notable  feature  in  the  columns  of  the  cord  in  general 
paralysis.  In  fact,  these  spider-like  cells  accumulate  in  vast  numbers, 
and  especially  along  the  vascular  tracts,  giving  these  regions  a  deeper 
staining  in  aniline  preparations  quite  appreciable  to  the  naked  eye. 
Such  tracts,  consequently,  look  at  first  sight  like  sclerosed  tissue, 
until  microscopic  examination  resolves  them  into  large  numbers  of 
deeply-stained  spider-cells.  They  are  by  no  means  peculiar  to  general 
paralysis,  as  they  are  found  in  these  columns  also  in  chronic  inflam- 
matory conditions,  in  all  long-standing  congestions  of  the  cord,  in  alco- 
holism, and  in  senile  atrophy  of  the  cerebro-spinal  system.  A  genuine 
sclerosis,  such  as  is  seen  in  primary  tabes,  we  do  not  find ;  no  finely- 
punctated  connective  tissue  pervades  these  columns  of  the  cord,  so  that 
the  uniformly-deep  tinge  of  stained  preparations  is  not  so  frequent 
a  feature  here.  The  increase  is  simply  that  of  the  lymph-connective 
system,  apparently  stimulated  by  the  engorged  condition  of  the  vascu- 
lar apparatus  and  the  defective  elimination  dependent  thereupon. 


506  PATHOLOGICAL    ANATOMY    OK    r;ENKKAL    PARALVSLS. 

The  Nervous  Elements. — As  above  stated,  those  often  remain 
little  or  not  at  all  implicated.  No  enlarged  axis-cylinders  are 
observed,  no  swelling  of  the  meduUated  sheath,  no  proliferation  of 
nuclei ;  nothing  which  can  be  translated  into  signs  of  inflammatory 
implication  of  the  nerve-fibre.  The  spider  or  "  scavenger-cells  "  (as  we 
have  termed  those  elements)  appear  powerless  in  their  agency  upon 
medullated  nerve-tubes,  and  it  would  seem  that  their  destructive 
agency  directly  affects  only  the  \inprotected  protoplasmic  structures, 
the  nerve-cell,  the  axis-cylinder  process  before  it  attains  its  medullary 
investment,  or  the  protoplasmic  bi^anches  of  these  cells.  The  connec- 
tive elements,  however,  eftect  the  degeneration  of  the  medullated  tube 
by  the  pressure  and  encroachment  of  sclerous  fibrillated  tissvie,  as  seen 
by  the  invasion  of  the  finely-punctated  tissue  in  other  forms  of 
ascending  sclerosis. 

As  to  the  site  of  the  changes  just  considered,  the  postcriOP  COm- 
miSSUPal  zone  of  the  cord  is  a  special  favourite  site  of  election. 
Here  the  vascular  tracts  almost  invariably  exhibit  the  change 
described,  even  if  nowhere  else  observable.  The  COlumns  of  Goll 
are  likewise  often  implicated,  whilst  a  third  favourite  site  appears  to 
be  the  posterior  radicular  zone,  the  morbid  change  extending 
from  the  entrance  of  the  innermost  fibres  of  the  posterior  roots  into 
the  cord  along  their  course  until  they  enter  the  posterior  cornu.  The 
proliferating  scavenger-cells,  as  before  stated,  usually  follow  the  course 
of  these  morbidly-distended  vessels,  and  by  their  depth  of  staining 
map  out  the  posterior  column  into  a  riband-like  band  involving  one 
or  both  radicular  zones,  or  occupy  the  inner  wedge-shaped  extremity  of 
Goll's  column,  or  form  a  deep-coloured  belt  immediately  behind  the 
posterior  commissure.  In  such  cases  the  substantia  g'elatinosa  of 
the  posterior  cornu  is  riddled  throughout  by  similar  dilated  blood- 
channels.  This  increased  vascularity  may  pervade  the  whole  of  the 
central  grey  matter,  as  well  as  the  lateral  columns. 

System-Implication  of  Lateral  Columns. — When  these  coluinns 

are  involved  the  indications  presented  are  those  of  chronic  and  mild 
congestion  leading  to  eventual  sclerosic  degeneration  of  the  tissue.  In 
fresh  preparations  such  changes  may  not  l)e  appreciable  to  the  naked 
eye,  and  (unlike  the  secondai-y  degenerations  from  focal  lesion  in  the 
cerebrum)  they  are  not  revealed,  except  to  histological  examination. 
In  the  ordinary  forms  of  descending  lateral  sclerosis  consecutive  to 
desti'uctive  lesions  in  the  motor  area,  the  degenerated  columns  betray 
themselves  by  their  greyish  translucent  aspect,  showing  through  the 
pia  just  as  the  ascending  sclerosis  of  genuine  tabes  reveals  itself  by 
the  same  peculiar  pearly  translucency  in  the  posterior  columns.  The 
naked-eye  examination,   however,  may   indicate  its  existence  by  the 


ASSOCIATED    SVSTEM-DISKASKS    OF    THK    COHD.  507 

altered  contour  of  the  cord,  the  column  implicated  being  often  shrunken, 
contracted,  and  the  normal  symmetry  distorted.  Again,  section  of  the 
fresh  cord  in  the  former  affection  (descending  lateral  sclerosis)  exhibits 
the  degeneration  to  the  naked  eye  as  a  greyish,  brownish,  or  fawn  tint, 
and  a  translucency  due  to  the  diminution  of  medullated  sheaths  of 
the  nerve-fibres,  as  also  to  the  preponderance  of  enlarged  blood-vessels 
and  connective  elements.  In  the  lesions  of  these  columns  in  general 
paralysis  these  appearances  are  observed  only  where  the  process  has 
been  unusually  active;  in  the  great  majority  of  cases  they  require 
microscopic  examination  of  specially-hardened  chrome-specimens  to 
reveal  the  degenerative  condition. 

What  is  observed  in  such  sections  prepared  and  stained  by  the  usual 
means  is  the  deep  tint  taken  up  by  the  diseased  tract;  the  vessels  and 
trabecular  tissue  and  intervening  connective  being  so  far  predominant 
as  to  take  up  much  more  of  the  staining  reagent  than  the  healthy 
tracts,  where  the  axis-cylinder  is  ensheathed  by  its  normal  amount  of 
myeline;  if,  before  staining,  such  sections  are  "cleared  up"  and  examined 
by  transmitted  light,  the  peculiar  translucent  aspect  of  the  diseased 
tracts  also  suffices  to  map  them  out  accurately  to  the  naked  eye.  The 
intimate  nature  of  the  process  is  revealed  by  histological  examination. 
It  is  thus  found  that,  in  the  posterior  half  of  the  lateral  column,  reach- 
ing back  to  the  posterior  cornu,  but  bounded  externally  by  a  tract  of 
healthy  nerve-tissue — the  direct  cerebellar  tract — there  is  a  dark-stained 
area  in  which  the  nerve-elements  are  in  a  state  of  inflammatory 
disintegration.  The  medullated  fibres  have  lost  a  great  part  of  their 
myeline,  and  are  notably  diminished  in  size — their  axis-cylinders, 
however,  still  remaining;  here  and  there  the  nerve-fibres  appear  larger 
than  usual,  the  medulla  swollen — faintly  tinted  with  the  dye  (an 
indication  of  its  necrotic  stage) — and  the  axis-cylinder  either  displaced 
laterally  or  entirely  absent.  These  enlarged  fibres,  seen  in  transverse 
sections,  are  but  the  swollen  moniliform  portions  of  the  disintegrating 
nerve-fibre  divided  at  its  lai'gest  diameter.  To  indicate  this  fact, 
longitudinal  sections  through  the  column  should  be  made,  and  examined 
in  the  fresh  and  in  the  mounted  state.  The  nerve-fibres  will  then  be 
seen  to  be  undergoing  marked  inflammatory  change;  a  large  proportion 
may  exhibit  almost  empty  medullated  sheaths,  enclosing  a  still- 
continuous  axis-cylinder;  in  most  cases  the  axis-cylinder  is  itself 
izaterrupted,  displaced,  contoi'ted,  and  severed  along  its  course;  the  less 
degenerate  fibres  show  irregular  enlargements  along  their  course,  often 
presenting  a  notably-moniliform  asj)ect  due  to  proliferation  of  tlie 
nerve-nuclei,  increase  of  their  protoplasm,  and  segmentation  of  the 
medulla  thus  induced;  in  fact,  an  active  destructive  process,  in  which 
these  nucleated  masses  of  protoplasm  forming  the  cellular  element  of 


508  PATHOLOGICAL    ANATOMY    OF   r.ENEHAL    PAFJALYSLS. 

each  segmented  node  of  the  nerve-iibro  take  the  eliief  part,  a  process 
clearly  enunciated  by  Rjinvier.  If  these  longituflinal  sections  are 
examined-  in  the  unmounted  state  prior  to  the  clearing  up  with  oil  of 
cloves,  the  fibres  are  also  seen  to  have  freely  scattered  over  them  a 
large  quantity  of  compound  granule-cells — another  indication  of  the 
inflammatory  change.  These  gi'anule-masses  are  immediately  lost  upon 
the  use  of  this  clearing  reagent,  but  may  be  temporarily  preserved  by 
mounting  in  glycerine. 

Returning  to  our  transverse  sections  of  these  columns,  we  find  the 
trabecular  tissue  largely  increased,  its  radiating  cells  enlarged,  and 
much  fine  punctated  fibrillar  tissue  (deeply-stained)  intervening  betwixt 
the  degenerate  nerve-fibres,  and  following  out  especially  the  direction 
of  the  vascular  tracts.  The  vessels  themselves  are  unduly  large,  and 
very  prominent  in  the  diseased  part;  their  walls  are  invariably 
thickened,  the  muscular  tissue,  more  especially,  being  thus  increased; 
■whilst  the  smaller  vessels  exhibit  the  change  more  notably  than  the 
larger;  in  many  cases  the  lumen  may  be  almost  obliterated.  The 
lymphatic  sheath  may  be  distended,  but  this  change  is  not  so  prominent 
a  feature  as  in  the  common  form  of  lateral  sclerosis  from  cerebral  focal 
disease;  nor,  upon  the  other  hand,  does  it  approach  to  the  remarkable 
change  seen  in  corresponding  tissues  in  the  cortex  of  general  paralysis. 
The  vessels  themselves  usually  form  centres  from  which  connective  tissue 
radiates  into  the  surrounding  nervous  structures  placed  in  the  axil  of 
the  trabecula;  the  open  lumen,  the  thick  wall  of  the  vessel,  and  its 
occasionally  distended  sheath  are  prominent  objects,  and  the  radiate 
cells  around  thrust  out  their  processes  into  the  finely-punctated 
connective  in  which  the  nerve-fibrils  are  imbedded.  The  appearance  is 
almost  suggestive,  at  first  sight,  of  primary  interstitial  change;  but  this 
can  scarcely  be  maintained  in  view  of  the  fact  tliat  the  vessels  may  be 
traced  through  healthy  tissue  (such  as  pass  through  the  direct  cerebellar 
columns)  into  the  diseased  focus,  and  that  only  on  their  arrival  in  the 
inflamed  zone  do  they  present  the  morbid  appearances  described.  The 
same  statement  holds  good  for  ordinary  descending  sclerosis,  secondary 
to  cerebral  lesions;  here,  also,  we  witness  the  implication  of  the  vessel 
only  upon  its  arrival  at  the  site  of  morbid  activity.  Again,  we  do  not 
meet  with  the  enormous  nuclear  proliferation  upon  the  walls  of  these 
arterioles,  such  as  we  found  in  the  cortex;  the  adventitia  is,  as  a  rule, 
devoid  of  any  undue  proliferation.  It  is  not,  however,  intimated  by 
this,  that  a  true  parenchymatous  neuritis  may  not  induce  such  nuclear 
proliferation  by  extension  of  the  inflammation  to  the  vascular  tracts 
and  interstitial  tissue;  but,  that,  in  the  absence  of  this  change,  we 
probably  have  positive  evidence  of  an  inflammatory  extension  to  the 
blood-vessel  not  having  occurred.     A  still  more  important  indication 


"PlaieXiV. 


FigTn.erd.ed  aridi  shruTil-cen  apex. 


Piarncntecl  ^ranide    mass^ 


^iTimken  &.  displaced  nucleus 


\         » 

_^^'<^i^-m£nied  OTanular  mass. 


Process  contimzczis  ivUh 
retracted  -protoplas-f. 


Tusccus     de^  eTiereitioTi    of  large   Ganglioz^ic   cells 
of    Motor    Cortex  ,  lL\xiin.aTi.  x350. 


PARENCHYMATOUS    MYELITIS.  509 

of  the  change  being  primarily  a  ixirenchymatous  neuritis  is  found  in  the 
tendency  of  the  lesion  to  assume  a  genuine  system-distribution;  and 
the  argument  holds  good  for  these  changes  in  the  lateral  columns  of  the 
cord  in  general  paralysis,  just  as  Gowers  indicates  that  it  does  for  the 
system-disease  of  tabes  dorsalis. 

Assuming,  then,  that  the  changes  met  with  in  the  lateral  columns  of 
the  cord  in  general  paralysis  are  of  the  nature  of  a  parenchymatous 
i-ather  than  an  interstitial  myelitis,  and  that  this  change  tends  to 
establish  a  system-disease  of  the  cord,  we  naturally  ask  how  the 
change  is  primarily  induced.  Why  do  the  nerve-fibres  take  on  the 
inflammatory  condition  described  1  There  can  be  little  doubt  that  the 
true  explanation  lies  in  the  destructive  and  irritating  lesions  proceed- 
ing in  their  trophic  centres  in  the  cerebrum ;  for  we  may  safely  assume 
that  the  cortical  cells  in  communication  with  such  motor  fibres  also 
exert  a  trophic  influence  over  them.  The  initiatory  change,  viz.,  the 
increase  of  the  nucleated  protoplasts  of  the  medullated  nerve-tubuli, 
we  do  know  occurs  as  the  result  of  its  separation  from  its  trophic 
centre,  as  by  section  or  other  lesion;  and  we  trace  in  the  cortex 
lesions  of  motor  cells  which  indubitably  should  lead  to  the  changes 
described.  It  is  a  significant  fact,  also,  that  one  of  the  earliest  indica- 
tions of  the  change  is  the  extreme  vascularity  of  the  tract  afiected,  in 
itself,  possibly,  the  expression  of  the  trophic  disturbance.  To  sum- 
marise these  views  : — 

1.  The  change  is  induced  secondarily  to  the  cortical  lesions. 

2.  It  establishes  itself  after  the  WaUerian  principle  ;  does  not 
overstep  its  systematic  barrier,  although  it  may  originate  simultaneously 
at  several  distinct  and  distant  parts  of  this  tract. 

3.  It  reproduces,  in  varying  degrees  of  intensity,  the  character  of  a 
chronic  parenchymatous  myelitis  with  notable  vascular  change. 

4.  Its  intensity  never  approaches  that  of  the  descending  myelitis 
due  to  large  focal  lesions  of  the  cortex,  and  being  in  its  essential  nature 

dependent  upon  a  gradually-advancing-  deg'eneration  of  cortical 

nerve-cells,  and  not  a  sudden  or  gross  lesion  such  as  the  former,  the 
irritative  influence  on  the  cord  is  greatly  mitigated. 

Although,  in  the  greater  number  of  cases,  the  change  found  in  the 
posterior  columns  of  the  cord  is  limited  to  the  vascular  distension 
above  alluded  to,  and  the  abundant  production  of  scavenger-cells  ;  yet, 
in  certain  instances,  we  meet  with  a  genuine  myelitis,  the  site  of  which 
is  usually  the  posterior  radicular  zone,  often  extending  across  towards 
the  columns  of  Goll.  Here,  the  nerve-tubuli  have  veritably  undergone 
inflammatory  change ;  and,  as  will  be  described  more  fully  in  the 
lateral  columns,  the  medullated  sheath  is  found  swollen,  faintly  stained, 
the  site  of  nuclear  proliferation  and  disintegration  of  myeline.     Many 


510  PATHOLOfJICAL    ANATOMY    OF    OENERAL    PARALYSIS. 

of  these  enlarged  tubuli  show  no  axis-cylinder  or  one  which  is  displaced 
laterally,  and  the  increase  of  connective  along  the  vascular  tracts  often 
leads  to  a  notable  diminution  and  distortion  of  these  columns  of  the 
cord.  The  ordinary  grey  degeneration  of  these  columns  seen  in  tabes 
(lorsalis  is  not  in  these  cases  reproduced,  hut  a  much  more  irritative 
process,  highly  inflammatory  in  character,  and  closely  resembling  the 
sclerosic  conditions  of  the  lateral  columns  with  which  it  is  often 
associated.     (PI.  vi.,Jigs.  1-3;  PI.  vii.) 

Combined  System-Implication  of  Columns.— Do  the  changes 

found  ever  resemble  those  of  amyotrophic  lateral  sclerosis  1  We  need 
only  refer  to  the  case  of  M.  J.  R.  (p.  278)  for  a  typical  illustration  of 
this  amyotrophic  sclerosis  associated  with  general  paralysis.  Such 
cases  present  a  very  rapid  downward  career,  which  is  mapped-out  in  the 
earlier  stage  by  successive  apoplectiform  and  convulsive  seizures  ;  the 
latter  are  usually  unilateral,  often  limited  to  the  facial  muscles,  and 
unattended  by  loss  of  consciousness.  As  a  sequel  to  this  seizure  or  "fit," 
as  the  friends  term  it,  a  loss  of  power  in  one  or  other  limb  is  almost 
universally  found  to  exist;  usually  it  is  the  arm  that  suffers  most  after 
these  attacks,  the  grasping  power  being  greatly  diminished,  and  the 
subsequent  changes  in  the  muscular  power  and  nutrition  of  this 
member  may  be  disturbed  in  advance  of  the  lower  extremities. 
These  paretic  states  at  first  may  be  very  transient,  or  last  a  day 
or  more ;  the  locomotion  continues  unimpaired,  the  general  nutrition 
of  the  body  may  be  unaffected,  and  exercise  be  taken  without 
inducing  fatigue  for  a  period  of  one  or  two  years  subsequent  to  the 
onset  of  the  cerebral  disturbance.  Then,  there  appear  symptoms 
which  inaugurate  the  advent  of  organic  changes  in  the  cord ;  the 
locomotor  powers  may  still  be  good,  and  considerable  muscular  force 
may  be  exhibited,  but  equilibration  is  distinctly  disturbed,  and  al- 
though the  patients  may  be  able  to  approximate  their  feet  in  the 
erect  position,  and  close  their  eyes  with  but  slight  swaying,  yet  they 
stagger  considerably  in  attempting  to  walk  in  a  straight  line  (heel 
and  toe).  The  gait  gradually  indicates  advancing  ataxy,  the  legs 
are  thrown  out  in  disorderly  fashion,  and  the  tendency  to  come  down 
on  the  heel  is  also  recognised.  Yet,  in  lieu  of  decreased  or  abolished 
knee-jerk,  we  now  find  either  that  it  is  normal  in  force  and  range,  or 
that  it  is  greatly  increased.  At  this  stage  also,  we  get  ankle-clonos 
in  one  or  other  limb  as  a  frequent  accompaniment.  The  tongue  now 
is  protruded  jerkily,  and  all  its  movements  are  ataxic,  the  lips  may 
be  exceedingly  tremulous,  but  deglutition  is  unimpaired. 

Attacks  of  maniacal  excitement  may  now  precede  sudden  failures  of 
power  in  the  lower  extremities,  and  we  find  ankle-clonos  and  the  knee- 
tap  reaction  in  excess.     The  arms  now  rapidly  emaciate,  and  become 


AjMyotropiiic  form.  511 

correspondingly  defective  in  muscular  power  ;  in  fact,  the  most  marked 
feature  of  the  case  at  this  period  will  be  this  extreme  atrophy  of  the 
upper  extremities,  in  which  the  more  specialised  muscles  are  not 
picked-out  in  the  manner  of  the  ordinary  progressive  muscular  atrophy, 
but  the  large  muscles  of  the  shoulder-joint,  the  musculature  of  the  arm, 
and  the  flexors  and  extensors  of  the  forearm  are  chiefly  involved.  No 
contractures  of  the  arm  occur,  or  myotatic  increase,  but  complete 
flaccidity,  and  the  legs  do  not  participate  in  this  subacute  atrophic 
state.  On  the  other  hand,  the  legs  show  more  marked  sensory  dis- 
turbances, cutaneous  sensibility  becomes  blunted,  there  is  increased 
swaying  in  the  erect  position,  the  gait  may  be  that  of  an  unsteady 
jog-trot,  or  more  notably  ataxic.  Exalted  knee-jerk  and  clones  may 
still  exist ;  but,  muscular  enfeeblement  now  rapidly  supervenes ;  the 
limbs  tend  to  exhibit  spasmodic  fixation,  but  are  more  frequently 
kept  stiff  and  rigid  by  voluntary  effort.  The  patient  is  now  bed- 
ridden, and  at  this  stage  is  usually  profoundly  demented.  Implication 
of  the  sensory  nerve-roots  becomes  evidenced  by  almost  complete  loss 
of  cutaneous  sensibility  in  one  or  both  legs,  and  is  probably,  also, 
indicated  by  a  sharp  distressing  cry  often  repeated,  as  if  the  poor 
patient  were  the  subject  of  sudden  lightning-pains.  Ataxy  is  also 
now  present  to  a  very  notable  degree,  and  the  knee-jerk  (up  till  this 
period  normal,  or  unduly  exaggerated)  is  completely  aboHshed ; 
plantar-reflex  is  also  absent.  By  this  stage  the  subject  is  in  a 
pitiable  condition,  helpless  in  limb,  utterly  incapable  of  attending 
to  the  most  trivial  wants,  exceedingly  timid,  and  the  apparent  sufferer 
from  fulgurant  pains;  there  is  profound  implication  of  the  bulbar 
nerves,  deglutition  being  so  far  impaired  as  to  make  the  effort  both 
painful  and  full  of  risk ;  whilst  softened  food  placed  in  the  mouth  is 
apt  to  be  retained  as  a  bolus  in  the  cheek-pouch  for  hours,  unless  care 
be  taken.  The  extreme  emaciation  of  the  upper  extremities  is  also 
attended  by  rapid  atrophy  of  the  facial  muscles,  loss  of  all  adipose 
tissues,  and  a  sharpened  pinched  expression  of  the  features. 

Reverting  now  to  the  amyotrophic  form  described,  we  note  first, 
that  the  spinal  appear  consecutively  to  the  cerebral  derangements  ; 
and,  as  before  stated,  are  almost  invariably  ushered-in  as  the  direct 
results  of  apoplectiform  or  convulsive  seizures.  The  resulting  paresis 
is,  at  first,  nothing  more  than  the  post-convulsive  exhaustion,  often 
seen  in  epileptics,  in  whom  also  the  myotatic  increase  indicated  by 
the  knee-jerk  and  ankle-clonos  is  often  seen ;  but,  eventually,  the 
inco-ordination  established,  apart  from  defect  of  sensation  or  patellar 
reaction,  indicates  a  morbid  change  in  some  region  of  the  cord,  other 
than  that  of  the  posterior  sensory  roots,  and  this  change  is  detected 
across  the  columns  of  Goll,  and  partly  in  the  2^ost-co7)wiissural  zone,  the 


512  PATHOLOGICAL    ANATOMY    OF    (iENKUAL    PARALYSIS. 

implication  of  wliitli  undoubtedly  leads  to  inco-ordinate  action,  with- 
out further  derangement  of  cutaneous  or  muscular  sensibility.  In 
fact,  a  morbid  basis  is  established  for  the  muscular  excitability 
indicated  by  the  increased  knee-jerk  in  a  finely-punctated  sclerosis  of 
the  lateral  columns  of  the  cord,  which  may  be  traced  from  the  dorsal 
cord  throughout  the  lumbar  region,  but  it  may  not  be  at  all  apparent 
in  thece  rvical  region.  {PI.  vii.)  It  is  to  the  increase  of  this  sclerosic 
state  of  these  columns  we  must  attriVjute  the  progressive  stiffening  of 
the  lower  limbs,  and  their  exalted  muscular  irritability.  Later  on  in 
the  history  of  these  cases,  the  changes  noted  in  the  columns  of  Goll 
spread  obliquely  outwards  so  as  to  directly  involve  the  posterior  sensory 
root-libres,  inducing  thereby  the  notable  ataxy  and  anaesthesia  of  the 
limbs  ;  but  still  exhibiting  betwixt  lower  and  upper  limbs,  the  contrast 
of  rigidity  of  the  former  (associated  with  no  special  wasting)  and  of 
extreme  atrophy,  paresis  and  flaccidity  of  the  latter.  As  regards  the 
arms,  the  changes  found  in  the  anterior  cornua  suffice  to  indicate 
the  cause  of  extreme  emaciation  of  certain  muscular  groupings,  and 
their  progressive  enfeeblement  in  motor  power.  {PL  xiii.j  The 
lesions  in  the  multipolar  cells  of  the  cornua  also,  in  like-manner, 
explain  the  complete  flaccidity  of  this  member,  for  in  this  region  the 
lateral  columns  are  not  diseased.  Charcot's  view  of  amyotrophic 
lateral  sclerosis  cannot  be  advanced  here ;  for  we  plainly  see  a 
degenerative  atrophy  of  the  cornual  elements  at  a  plane  considerably 
higher  than  any  change  indicated  in  the  lateral  columns  of  the  cord ; 
the  latter,  in  fact,  is  first  seen  in  the  dorsi-lumbar  region,  not  in  the 
cervical,  whereas  the  degeneration  of  the  anterior  cornua  is  first 
seen  in  the  cervical  region.  That  the  latter  is  established  by  a  sort 
of  projection  of  the  disease  forwards  from  the  lateral  columns  is, 
therefore,  here  quite  untenable,  nor,  in  fact,  can  any  relationship 
betwixt  the  two  be  aiffirmed ;  and  this  accords  completely  with  what 
we  constantly  see  in  ordinary  descending  lateral  sclerosis  from  focal 
cerebral  lesion,  where  the  lateral  columns  may  remain  for  eight  or 
ten  or  more  years  profoundly  implicated,  with  no  obvious  change  in 
the  cornua.  Evidently,  then,  this  disease  in  the  anterior  cornua  of 
the  cervical  and  the  lateral  sclerosis  of  lower  regions  of  the  cord  are 
independent  states,  mutually  related  only  as  regards  a  community  of 
origin  higher  up  in  the  cerebral  cortex.  Why  it  is  that  the  cornua 
are  afiected  in  the  cervical,  and  the  lateral  columns  in  the  dorsi- 
lumbar  cord,  can  probably  be  explained  only  by  the  special  localisation 
and  depth  of  lesion,  or  degenerative  change  within  the  cerebral  cortex. 
Then,  again,  as  regards  the  posterior  columns  of  the  cord ;  we  find 
here  the  frequent  vascular  change  observed  in  general  paralysis,  and 
the    aflections   whereby    the    cortical    lesions    tend    to    project   their 


PSEUDO-TABETIC    EOItM.  513 

influence  upon  subordinate  regions  of  the  spinal  axis ;  the  vascular 
turgescence,  however,  is  not  so  great  in  these  cases  as  the  purely 
neural  change.  {PL  xvi.,  fig.  3.)  The  change  is  not  one  of  connective 
proliferation,  of  abundant  cell-growth  of  scavenger-elements,  or  of 
notably-enlarged  vessels  presenting  changes  in  their  tunics ;  it  is  not  a 
vascular  nor  interstitial  connection,  but  a  purely  neural  change — 
a  genuine  myelitis — tending  to  spread  exclusively  along  the  direction 
of  the  sensory  root-fibres,  as  indicated  in  the  description  above  given. 
No  cases,  in  fact,  would  better  indicate  to  us  the  neural  origin  of 
ascending  changes  in  general  paralysis,  and  in  certain  forms  of  tabes. 

If,  as  often  happens,  the  posterior  cornua  be  also  implicated  by 
extension  of  this  lesion  to  the  substantia  gelatinosa,  we  get  anaesthesia 
of  the  corresponding  limb. 

The  order  of  evolution  of  the  morbid  changes,  appear  to  be  as 
follows — first,  the  posterior  median  and  posterior  commissural  zones 
are  involved,  issuing  in  inco-ordinate  gait ;  next,  the  lesion  tends  to 
spread  over  the  whole  of  the  posterior  root-zone,  and  along  the  course 
of  its  sensory  fibres ;  at  the  same  time  progressive  degenerative 
changes  occur  in  the  lateral  columns  in  the  dorsi-lumbar  region.  Ere 
these  latter  changes  are  much  advanced,  amyotrophic  change  is 
observed  in  the  upper  extremities,  revealing  the  lesion  located  in  the 
anterior  cornua,  and,  subsequent  to  this,  a  rapid  ascending  change 
from  this  site  implicates  the  bulbar  nerve-nuclei,  and  hastens  on  the 
fatal  termination. 

Implication  of  Posterior  Columns  (Pseudo-tabetic  forms). — 

We  have  thus,  so  fai-,  dealt  with  a  combined  system-aflfection  of  the 
cord  in  general  paralysis,  where  a  postero-lateral  change  predominates 
in  the  lower  region,  and  a  polar  impairment  (issuiug  in  progressive 
general  muscular  and  bulbar  atrophy)  is  emphasised  in  the  cervical 
regions.  Let  us  now  consider,  more  particularly,  the  cases  where  the 
former  exclusively  exists.  {See  case  ofH.  U.,p.2^l.)  A  notable  feature 
in  this  class  of  cases  is  the  predominance  of  sensorial  derangements,  not 
as  regards  spinal  symptoms  only,  but  as  expressed  in  cerebral  symptoms 
also.  The  mental  anomalies  appear  specially  to  indicate  a  wide-spread 
sensorial  implication,  and  the  maniacal  perversions  are  characterised  by 
most  vivid  acute  hallucinations,  by  very  painful  emotional  states,  often 
culminating  in  attacks  of  the  most  acute  melancholia.  The  painful 
mental  states  are  all  associated  with  well-marked  hysteric  outbursts 
so  characteristic  of  this  series  of  cases.  It  is  only  in  the  later  stages 
of  the  disease,  when  the  dementia  is  fjxr  advanced,  that  this  painful 
state  of  mind  declines,  or  rather  is  replaced  by  a  condition  bordering 
upon  idiocy,  often  with  much  frenzied  excitement. 

Another  prominent  symptom  is  that  of  frequent  convulsive  attacks, 

33 


514  PATHOLO(;lCAL    ANATOMY    OF    GENKRAL    PARALYSIS. 

which  are  often  peculiarly  severe  in  nature,  and  leave  wide-spread  and 
notable  sequehe,  physical  and  mental.  When  such  a  case  presents 
itself,  we  are  struck  at  the  onset  by  the  marked  tabetic  gait,  a  feature 
especially  striking  if  the  subject  be  in  a  state  of  excitement.  The  feet 
are  planted  wide  apart,  the  legs  thrown  out  in  most  disorderly  style, 
and  the  heel  brought  down  with  disproportionate  force.  The  inco- 
ordination is  further  increased  by  closing  the  eyes,  and  the  patient 
cannot  stand  in  this  position  without  falling.  Yet,  muscular  power  is 
in  no  way  necessarily  impaired,  and  the  limbs  will  resist  forcibly  efforts 
to  extend  them.  Since,  however,  convulsions  are  very  frequent  in 
such  cases,  we  often  find  a  considerable  amount  of  paresis,  but  this 
only  of  a  ti-ansient  nature  at  first ;  great  fatigue  upon  slight  exertion 
may  be  complained  of,  or  the  grasping  power  diminished,  as  in  one  of 
our  cases,  to  4  kilogrammes.  No  permanent  paralysis  is  detected  in 
this  early  stage;  but  the  all-important  fact  to  recognise  is  the  complete 
absence  of  muscular  atrophy,  and  the  non-implication  of  the  cutaneous 
and  muscular  nerves.  Yet,  simultaneously  with  this  absence  of  sen- 
sory manifestation  in  lower  planes,  we  may  find  the  sensory  tract  of 
the  trigeminus  implicated — e.g.,  the  herpetic  eruption  and  trophic 
impairment  of  cornea  in  the  case  of  H.  U. 

The  ataxic  gait  is,  as  usual,  a  more  obtrusive  symptom  than  the 
same  impairment  in  the  movements  of  the  hand  and  arm ;  yet  an 
attempt  to  write,  to  button  the  coat,  to  sew,  or  thread  a  needle  at  once 
makes  evident  the  fact  that  the  inco-ordination  of  the  hands  is  as  gravely 
impaired  as  that  of  the  lower  extremities.  If  convulsions  occur,  they 
are  usually  unilateral,  or  much  more  marked  on  one  side  than  the 
other;  they  generally  leave  behind  them  a  hemiplegic  state,  often  with 
complete  hemiansesthesia.  The  reductions  from  such  convulsive  seiz- 
ures are  often  most  profound  and  prolonged,  the  subjects  being  left  for 
days  together  in  a  state  of  complete  stupor ;  mute,  requiring  forcible 
feeding  and  catheterism,  and  keeping  the  mouth  full  of  saliva.  Then, 
as  normal  sensation  is  regained  and  muscular  power  returns,  we  may 
have  wild  delirious  excitement,  which  may  be  associated  with  desperate 
suicidal  impulses.     (//.  U.,  p.  281.) 

Repeated  attacks  of  hemiplegia  with  more  or  less  complete  anes- 
thesia of  the  same  side  occur,  leaving  the  patient  speechless  and 
helpless  for  days,  until  eventually  the  aspect  of  the  case  is  one  of  utter 
imbecility.  In  the  intervals,  however,  between  such  seizures,  he  may 
still  go  about  exhibiting  notably  the  inco-ordinate  gait,  but  with 
normal,  or  more  often  with  acutely-exaggerated  knee-jerk.  Contractions 
of  the  limbs  now  ensue,  being  generally  limited  to  the  upper  ex- 
tremities, and  corresponding  to  the  side  usually  left  paralysed  after 
convulsive  seizures ;   thus,  in  a  case  of  right  hemiplegia  with  hemi- 


PSEUDO-TABETIC    FORM.  515 

anaesthesia  following  convulsive  attacks,  the  permanent  paralysis  and 
contracture  is  sure  to  develop  on  this  same  side.  Ushered-in  by 
slight  initial  rigidity  of  the  extensors  of  the  forearm  and  wrist  (which 
permit  of  wrist-  and  ankle-clonos  upon  slight  flexion),  the  flexors  soon 
antagonise  and  contract  the  arm  in  the  usual  semiflexed  and  pronated 
position.  In  this  advanced  stage  there  may  still  be  no  vasomotor 
change  in  the  limb,  and  no  indication  whatever  of  trophic  disturbance; 
but  at  a  still  later  stage  the  skin  of  the  feet  may  be  cold  and  bluish,  and 
a  co-existent  ancesthesia  may  be  noted  in  the  skin  of  the  calves,  the 
plantar  reflexes,  however,  still  remaining  brisk.  The  lower  extremities 
may  show  a  certain  degree  of  clasp-knife  rigidity,  or  spasmodic  fixation, 
but  no  permanent  contracture  ;  yet,  in  the  latest  stage,  the  repeated 
convulsive  seizures  so  far  exhaust  the  energy  of  the  motor  tract,  that 
the  patient  sits  squatting  in  stooping  posture,  or  attempts  locomotion 
on  hands  and  knees.  Deglutition  may  be  little  impaired  except  as  the 
immediate  result  of  epileptiform  seizures;  grinding  of  the  teeth  is  a 
very  frequent  accompaniment. 

From  the  first  series  these  cases  are,  of  course,  notably  distinguished 
from  the  outset,  by  the  far  greater  obtrusiveness  of  inco-ordination, 
which,  at  first  sight  typically  tabetic,  is  subsequently  found  wanting 
in  that  implication  of  the  sensory  nerve-roots  which  would  render  it 
a  genuine  tabetic  condition.  No  disturbance  of  muscular  or  cutaneous 
sensibility,  however,  is  discoverable,  except  as  the  immediate  outcome 
of  a  cerebral  discharge.  Such  cases  conclusively  prove  that  inco- 
ordination may  result  from  lesions  in  the  regions  of  the  posterior 
columns  other  than  the  posterior  root-zone;  and  that  the  posterior  root- 
fibres  must  be  implicated  to  explain  any  existing  sensory  anomalies  of 
skin  and  muscles.  We  find  in  the  cases  presented  by  this  series  that 
the  postei"ior  root-zone  is  absolutely  free  from  disease ;  and  that  any 
morbid  implication  of  the  posterior  columns  of  the  cord  is  exclusively 
limited  to  the  posterior  commissural  zone  and  posterior-median  columns 
(columns  of  Goll),  in  cervical,  dorsal,  and  lumbar  divisions  of  the  cord; 
this  implication  of  the  columns  of  Goll  with  a  perfectly  healthy  state 
of  the  sensory  root-fibres  we  have  repeatedly  recognised.*  The  lesion 
observed  differs  also  from  that  of  the  former  series  in  being  a  much 
more  pronounced  vascular  and  cellular  change.  The  vessels  of  the  pos- 
terior commissural  zone  being  notably  dilated,  and  extending  down  the 
median  raphe,  are  accompanied  by  a  dense  crowding  of  scavenger-cells 
(the  abundant  proliferation  of  which  is  a  striking  feature)  presenting  a 
coarse  trabecular  appearance,  in  which  thick-walled  vessels  with  con- 
tracted lumen  are  freely  scattered.     (PI.  xvi.,  Jig.  3;  PI.  xviii.)     The 

*  See  in  this  connection  the  microscopic  examination  of  the  cord  in  tlie  case  of 
H.  U.,  p.  282. 


516  PATHOLOGICAL    ANATOMY    OF    GENERAL    PARALYSIS. 

nerve-fibre  does  not  itself  appear  implicated  as  in  the  former  series, 
and  the  disturbances  in  their  oonductibility  are  pnjbably  the  result 
of  the  pressure  produced  by   this   morbid   cellular  growth,  and  the 
engorged  and  distended  nutrient  vessels  of  this  region.     The  mor])id 
change  in  tissue  follows  out  very  accurately  the  immediate  confines 
of  Goll  along  the  inner  half  of  the   wedge-shaped   apex,   where    it 
lies  in  contact  with  the  columns  of  Burdach,  respecting  rigidly  the 
posterior  root-zone,  however;  but,  the  columns  are  throughout  their 
inner  half  the  site  of  such  change,  especially  along  the  median  raphe. 
It  would  appear  highly  probable  that,  in  those  cases  where  inco-ordina- 
tion,  existing  notably  ybr  a  time  only,  has  gradually  declined  or  wholly 
disappeared,  the  phenomena  may  be  regarded  as  2)'>'^ssure  results  which 
have  not  proceeded  to  actual  myelitis,  and  in  which  the  scavenger-cells 
have  performed    their  depurative  functions   (p.  497)  and    have   been 
replaced  by  fibrillated  tissue.     The  muscular  tone  in  all  these  cases  is 
but  slightly,  if  at  all,  impaired ;  and  the  anterior  cornua  remain  intact, 
as  evidenced  by  the  well-nourished  aspect  of  the  muscles  late  on  in  the 
disease ;  no  centric  atrophy  of  the  limbs  is  seen  as  in  the  former  cases. 
The  general  muscular  debility  and  fatigue  upon  slight  exertion,  which 
such  cases  present,  are  the  outcome  of  the  exhaustive  convulsive  seizures 
to  which  they  are  so  subject,  and  not  of  a  persistent  paralysis   or 
atrophic  change  in  the  muscles  of  the  limb.     The  descending  changes 
in  the  lateral  columns  always  appear  as  the  sequel  of  the  convulsive 
seizures  above  alluded  to,  and  explain  the  association  of  exaggerated 
knee-jerk  with  the  inco-ordinate  movements  of  the  limbs;  such  sclerous 
change  implicates,  as  before  stated,  the  greater  part  of  the  column, 
respecting,  however,  the  direct  cerebellar  and  intermedio-lateral  zone,  it 
yet  creeps  forward  as  far  as  the  postero-external  group  of  cells  in  the 
anterior  cornu.     The  change  occurring  in  the  posterior  median  tracts 
of  the  cord  is  earlier  in  its  incidence  than  this  lateral   sclerosis,  as 
shown  by  the  much  larger  development  of  contractures  in  the  limb 
after  a  long  persistence  of  inco-'ordination.     Then  we  have  to  consider 
the  association  of  the  cortical  implication  with  these  spinal  changes. 
It   is    in   such   cases   we    get   little,    if  any,    indication   of  adherent 
membranes,  and  the  atrophic  state  of  cortex  will  be  chiefly  located  in 
the  upper  parietal  or  postero-parietal   lobule.      We  have  elsewhere 
indicated  the  association  of  lesions  at  this  site  with  ti-emulous  and 
ataxic    movements    of    the    lower    limbs,*    and    it   appears    to   the 
writer   probable,    that   the   implication   of   the   posterior  columns  of 
the   cord,    at    the    side    named,     has     some    direct   originating   con- 
nection with  the  extreme  atrophy  undergone  in  the  postero-parietal 
lobule. 

*  "Localisation  in  Cerebral  Disease,"  Brit.  Med.  Jour.,  vol.  ii.,  1883. 


TABES    AND    GENERAL    PAIJALYSIS.  517 

The  absence  of  muscular  atrophy,  which  characterised  tlie  former 
series  of  cases,  is  consistent  with  the  immunity  of  the  anterior  c<jrnua 
from  morbid  change. 

Waiving  for  a  time  any  consideration  of  a  presumed  identity  in  such 
apparently  different  neuroses  as  tahes  and  general  paralysis,  if  the 
question  be  put  as  to  the  frequency  of  association  of  the  two  aflfec- 
tions  so  named,  the  reply  would  possibly  be  in  favour  of  a  very 
infrequent  alliance  as  observed  in  asylum  practice.  Nor  would  this 
opinion  be  surprising  if  we  remember  that  the  most  obtrusive  symptoms 
associated  with  tahes  is  one  not  by  any  means  essential  to  the  diseased 
process  which  is  at  the  root  of  the  ailment.  InCO-OPdination — so 
prominent  a  feature  in  all  marked  cases  of  tabeS  dorsalis — need  not 
be  present  to  constitute  this  disease ;  and,  if  ataxiC  symptoms  are 
considered  as  essential  features  in  tahes,  then  the  incidence  of  such  an 
affection  during  the  evolution  of  general  paralysis  would  very  justly 
be  regarded  as  most  infrequent. 

If,  however,  we  adhere  strictly  to  what  is  accepted  as  the  patho- 
logical definition  of  tahes,  viz.,  an  affection  of  the  posterior  nerve-roots 
or  the  peripheral  sensory  nerves,  and  accept  as  its  essential  clinical 
feature  the  abolition  of  knee-jerk,  then  we  do  find  evidence  in  favour 
of  a  very  frequent  association  between  these  affections. 

There  is  substantial  evidence  (both  clinical  and  pathological)  in 
favour  of  this  severance  of  ataxic  symptoms  from  the  truly  tabetic 
sign — loss  of  knee-jerk ;  and  the  position  assumed  by  Dr.  Gowers  in 
favour  of  such  severance  appears  to  us  unassailable.  There  is  undoubt- 
edly an  ataxic  paraplegia  without  the  knee-tendon  accompaniments  of 
tabes;  there  are,  moreover,  forms  of  indubitable  tabes  which  exhibit 
no  inco-ordination.  On  the  other  hand,  we  have  i-epeatedly  verified 
these  data  upon  pathological  grounds,  and  recognise  lesions  of  a  special 
region  of  the  posterior  columns  not  implicating  the  posterior  nerve- 
roots  as  the  essential  condition  associated  with  iuco-ordinate  move- 
ments of  the  limbs,  the  knee-jerk  being  normal  or  exaggerated  ;  whilst 
implication  of  the  posterior  nerve-roots  was  invariably  associated  with 
the  abolition  of  that  reflex  phenomenon.  Hence,  a  fallacy  is  likely  to 
occur  in  our  estimate  of  the  frequency  of  association  of  these  two 
cerebro-spinal  neuroses ;  just  as  in  the  ordinary  form  of  tahes  the  loss 
of  the  knee-jerk  is  a  symptom  which  may  precede  the  more  obtrusive 
evidence  of  the  disease  by  many  years,  being  a  symptom  which  is  apt 
to  escape  detection.  It  is,  indeed,  generally  revealed  at  an  early  date, 
not  from  the  prominence  of  any  motor  inco-ordination,  but  from  the 
lancinating  pains  with  wliich  it  is  so  frequently  associated.  Tabes, 
therefore,  in  this  strict  sense  of  the  term,  occurs  in  fully  15-9  per  cent, 
of  general  paralytics  (see  Analysis,  p.  2G9),  a  fiiirly  large  proportion; 


518        PATHOLOGICAL  ANATOMY  OF  GENERAL  PARALYSIS. 

and  sucli  cases  exliibit  certain  features  wliich  justify  us  in  separately 
considering  the  class.* 

It  is  not,  however,  with  these  more  frequent  forms  that  we  are  now 
more  immediately  concerned,  hut  with  the  fur  less  frequent  associa- 
tion of  ataxic  tabes  with  general  paralysis. 

Implication  of  Posterior  Columns  (Ataxic  Tahes).— This  rare 

form  of  disease  claims  our  closest  attention,  not  alone  from  the 
acuteness  of  the  neurosis,  and  the  wide  sweep  of  the  nerve-storm  over 
the  most  distant  regions  of  the  nervous  system,  but  more  especially 
from  the  emphatic  testimony  borne  by  its  clinical  history  to  the  close 
alliance  (if  not  identity)  of  the  morbid  processes  underlying  tabes 
dorsalis  and  general  paralysis. 

The  attack  is  usually  ushered-in  by  cerebral  symptoms  which  may 
be  purely  mental,  and  of  the  nature  of  a  maniacal  or  melancholic  out- 
burst; or  an  apoplectiform  or  convulsive  seizure  may  occur,  such  as  not 
infrequently  present  themselves  about  the  onset  of  general  paralysis. 
When  mental  symptoms  predominate  they  have  usually  been  of  an  acute 
character,  tending  to  melancholic  agitation  with  impulses  to  suicide  or 
dangerous  aggressive  violence.  We  have  not  observed  the  wild  delirious 
state  seen  in  the  ataxic  paraplegia  last  described.  If  COng'GStive  or 
convulsive  seizures  usher  in  the  affection,  there  may  supervene  a 
ti-ansient  hemiplegia,  more  or  less  complete ;  and,  probably  as  a  sequel 
to  this,  we  first  recognise  the  inco-ordinate  movement  of  the  limbs.  We 
are  not  in  a  position  to  state  wlien  the  knee-jerk  declines,  from  the  fjict 
that  these  subjects  come  before  our  notice  for  their  mental  infii'mity  ; 
certain  it  is,  however,  that  it  was  lost  in  all  the  cases  which  presented 
themselves ;  whether  such  loss  occurred  (as  is  quite  possible)  before 
prominent  cerebral  disturbances  existed,  or  not,  is  a  subject  deserving 
further  inquixy.  A  notable  symptom  in  all  these  tabetic  general 
paralytics  is  a  severe  frontal  headache,  often  complained  of  to  the 
exclusion  of  all  other  symptoms. 

The  mental  state  is  peculiar  in  the  fact  that  it  is  wanting  in  the 
redundant  flow  of  spirits  exhibited  by  typical  paralytics,  even  where 
the  most  grandiose  notions  prevail.  The  emotional  states  associated 
with  ideas  of  extraordinary  wealth,  unusual  attainments,  or  wondrous 
capacities  for  action,  even  if  they  do  prevail,  are  tinctured  by  con- 
siderable discontent,  querulousness,  and  evidence  of  a  general  moi-al 
decadence.  The  subject  may  be  distrustful,  cunning,  treacherous,  and 
exhibit  sullen  gloom  and  despondency,  or  even  harbour  suicidal 
tendencies.  Dementia  may  not  obtrude  itself  on  our  notice  until  the 
cerebro-spinal  affection  is  far  advanced  ;  and  it  must  be  affirmed  that 

*  The  analysis,  moreover,  indicates,  if  we  include  cases  where  tlie  reflex  is  not 
completely  abolished,  the  still  higher  proportion  of  20'4  per  cent. 


fpM^ 


fS-l^SM^-^-K 


Gection  from  tlie  ascexLcLin^  frontal  convolutioxL  iu  a  case  of  SeTiile  airop]^. 
The  proliferation  of  corLTiective"  cells  of  the  nxppex  coxtical  layers 
IS    seen    iTivacLln^   tlie   vascular    tracts  and   nervous    elements  xlSO. 


Group,  of 
<coLven 


'up.  of     ,_       &avenqer-cell   surroiaided  ly  bil-globxRes. 


Faiiif  -products    accurmzlaiing 
'■~ound  SloodL-vessel 


-i('^:^ 


F„, '!v    disiii-te  2>TaiiOTi   of  periplieral    zone   (1=  layer)     of    Cortex 
in  a  case   of    advanced   Senile    atrophy    of  Brain  .  x  350 


Nerve -c^ll  iieTfcid  cf  processes 


Swollen  decjeneraiino 
Jferve-ceTL    •■•., 


Tibrillatina  Scavenger- cells. 


Scavenger  elements  filled  -mih granules. 


■i-w-r^'^l  ni.^i.rilearaiei  and  surrciindtd 
::lar  debris. 


TT^  i     o 


ATAXIC    TABES    AND    GENERAL    PARALYSIS.  519 

cerebral  symptoms  may  entirely  fail  to  manifest  themselves,  and  the 
patient  be  sent  from  under  asylum  supervision,  but  suffei'ing  from 
pronounced  ataxy  of  the  limbs,  and  other  symptoms  of  tabes  dorsalis. 

The  bulbar  symptoms  of  general  paralysis  are  not  necessarily  a 
prominent  feature ;  the  pupils  may  be  unequal,  and  respond  sluggishly 
or  not  at  all  to  light ;  the  tongue  and  facial  muscles  may  be  somewhat 
tremulous,  but  the  articulation  is  often  clear  and  distinct.  • 

On  the  other  hand,  the  spinal  symptoms  will  be  striking  features  in 
the  case ;  the  patient  plants  his  feet  in  the  manner  of  the  ataxic  upon 
a    wide    basis    of  support ;    when    he    approximates   them,    he    sways 
considerably  and  tends  to  fall ;  if  he  closes  his  eyes  he  must  inevit- 
ably fall ;    he   fails   to  walk    backwards,    and  forward  progression    is 
accomplished  by  disorderly   thrusts  of  the  leg,  first  to  one  side  and 
then  to  the  other,  the  heels  coming  down  with  a  forcible  stamp.     If 
he  be  placed  upon  his  back,  and  be  requested  to  resist  extension  of 
the  limbs,  he  exhibits  considerable  muscular  power,  and  the  grasp  of 
the  hand  may  be  unimpaired.     On  percussing  the  patella-tendons  the 
knee-jerk  is  found  absent,  whilst  the  plantar  and  superficial  reflexes 
may  all   be   present.     No    anaesthesia    or    other   sensory  defect   may 
prevail.     As  in  tj'^pically  tabetic  cases,  lightning-pains  may  still  further 
cloud  the  poor  victim's   life,  and  be  of  so   agonising  a  nature  as  to 
render  sleep  futile,  and  necessitate  frequent  recourse  to  morphia.     In 
all  cases  it  appeared  to  us  that  a  connection  could  always  be  established 
between  the  more  acute  cerebral  and  spinal  exacerbations.     The  ataxy, 
in  such  cases  as  we  describe,  is  more  frequently  emphasised  in  both 
upper  and  lower  extremities;  in  uncomplicated  tabes  it  is  the  legs 
which  chiefly  suffer,   and    tlie  arms  may   as   we   know   escape.     The 
ataxy,  however,  is  a  symptom  which  varies  in  degree  from  time  to 
time,  and  is  indubitably  worse  with  coincident  mental  exacerbations ;  the 
truly    tabetic    symptom — abolished    knee-jerk — however,    is    persistent, 
never  being  regained.     We  have  known  an  instance  in  which  both  ex- 
tremities were  thiis  ataxic;  notwithstanding  the  patient  was  able  to 
write  a  fairly  intelligible   letter,  although   with  considerable   painful 
effort  and  exhaustion.     This  was  the  case  in  the  subject  detailed  by 
my  colleague.  Dr.   Bullen,*  where  the  patient,  tortured  by  delusions 
of  persecution,  spent  many  hours  at  the  sacrifice  of  much  discomfort  in 
writing  down  his    morbid  experiences  and  recording  his  accusations 
against  his  imaginaiy  enemies.      In  this  case,  muscular  sense  was  so 
far  defective  that  he  could  not  touch  the  tip  of  his  nose  with  the  finger, 
when  the  eyes  were  closed,  after  repeated  trials,  nor  approximate  the 
tips   of  the  fingers   of  both   hands.     It  would   appear  also  from   the 

"''  "A  case  of  Locomotor  Ataxy  followed  by  General  Paralysis  of  the  Insane. " 
Brain,  April,  1888. 


520  PATHOLO(iICAL    ANATOMY    OF    (ilONKKAL    PARALYSIS. 

history  of  this  case  tliat  th(!  arms  were  first  affected  (the  reverse  of 
what  is  usual),  since  sk>venly  writing  first  drew  attention  to  the  fact 
of  manual  inco-ordination. 

The  pains  vary  much  in  character  and  distribution,  tljey  are  usually 
sudden,  sharp,  and  lancinating,  described  as  like  electricity  passing 
through  a  limb;  they  may  be  described  as  tearing,  agonising  pains  of 
momentary  duration  only,  or  as  "flashings  painS  "  as  one  patient 
described  them  ;  or,  again,  there  may  be  an  intense  burning  pain  over 
a  localised  spot,  as  the  knee  or  foot,  and  occasional  "  g"irdle  painS  " 
supervene.  RhGUmatoid  pains  are  almost  always  complained  of,  and 
the  patient  will,  at  times,  speak  of  a  spasmodic  jerk  of  the  whole  arm, 
due  (as  he  says)  to  the  pain ;  or  from  the  same  cause  the  leg  may 
suddenly  give  way  beneath  him,  and  he  drops  on  his  knees  momen- 
tarily powerless.  Thus  in  Dr.  Bullen's  case  "  there  was  momentary 
loss  of  power  in  right  leg,  with  dimness  of  vision  and  confusion 
occasionally,"  also  "  hy perse sthesia  over  the  area  of  Wrisberg."* 
Priapism  and  nocturnal  seminal  emissions  occur  at  an  early  stage 
of  the  affection  of  the  cord,  and  sexual  proclivities  are  engendered  at 
this  period,  often  colouring  the-,  delusional  concepts  of  the  subject,  his 
conversation  and  bearing  being  suggestive  of  satyriasis.  Impotency 
follows,  and  as  indicated  by  Dr.  Gowers,  usually  when  the  cremasteric 
and  ahdomhial  reflexes  fail  to  respond  to  normal  stimuli.  Hysteric 
symptoms  often  supplement  the  mental  derangements,  and  a  species  of 
insane  or  hysteric  cunning  is  a  prominent  feature.  In  these  hysteric 
outbursts,  we  have  seen  one  patient  assault  his  wife  with  the  most 
cowardly  and  uncalled-for  violence ;  others,  who  have  plotted  dex- 
terously and  with  cunning  persistence  and  mendacity  to  damage  the 
reputation  of  the  nurse  or  attendant  administering  to  their  wants ; 
and  others,  who  have  been  most  foul  and  obscene  in  their  language. 
This  association  of  hysteric  states  in  the  tabetic  general  paralytic 
should  be  remembered,  since  they  are  apt  also  to  simulate  symptoms 
and  to  deceive  grossly,  if  too  much  reliance  be  placed  upon  subjective 
indications. 

Delayed  conduction  along  the  sensory  strands  is  known  to  be  of 
frequent  occurrence  in  tabetic  subjects  at  a  certain  stage;  this  we  have 
witnessed  in  a  tabetic  general  paralytic  to  the  extent  of  twelve  seconds, 
which  elapsed  betwixt  pricking  the  sole  of  the  foot  and  the  registering 
of  the  sensation  felt. 

Gastric,  laryngeal,  and  rectal  crises  have  all  been  recognised  in  this 
neurotic  condition,  and  are  so  severe  at  times  as  to  render  the  patient 
desperately  and  determinedly  suicidal. 

Tabetic  General  Paralysis. — To  proceed  to  the   more   frequent 

*  Loc.  cit. 


gp:nuine  tabetic  form.  521 

class  of  tabetic  cases  in  general  paralysis  where  abolished  knee-jerk 
has  been  detected,  but  where  ataxy  is  absent  or  plays  quite  a  sub- 
ordinate part  in  the  symptomatic  role,  we  find  that  a  striking  feature 
in  the  mental  disturbance  is  the  almost  universal  prevalence  of  melan- 
cholic depression,  the  dejected,  hopeless  aspect  of  the  patient  notably 
contrasting  with  the  beaming  expression  of  the  typical  paralytic.  A 
basis  for  such  depression  is  usually  found  in  a  persistent  and  torment- 
ing sense-hallucination,  to  which  they  are  prone,  and  which  is  not 
unusually  of  a  sexual  nature.  One  case  long  observed  by  us  was 
subject  to  the  persecution  of  a  woman's  voice  from  the  neighbourino- 
town,  which  haunted  him  whenever  he  went  out  of  doors,  and  which 
prompted  him  to  mari-y  her;  the  hallucination  co-existed  even  with 
intense  depression  and  noisy  weeping.  It  is  in  these  hallucinatory 
states  we  find  an  explanation  for  another  frequent  association,  that  of 
suicidal  feelings  which  peculiarly  characterise  this  class  of  cases. 
Almost  all  such  cases  have  made  determined  attempts  to  take  their 
own  life  by  drowning,  hanging,  strangling,  or  like  desperate  means, 
prior  to  their  admission  to  an  asylum ;  and  their  subsequent  history  is 
only  too  confirmatory  of  this  dangerous  impulsive  tendency.  As 
dementia,  however,  advances,  the  more  acute  melancholy  usually 
declines  and  is  replaced  by  sullen  gloom  varied  by  fitful  periods  of 
cheerfulness,  in  which  we  perceive  the  characteristic  features  of 
general  paralysis — the  egoistic  state  and  optimism  ;  the  delirious 
agitation  of  the  purely  ataxic  forms  we  do  not  observe  in  such 
patients.  Occasionally,  but  rarely,  optimism  may  be  from  the  onset 
a  prominent  feature;  there  is  in  such  a  case  advanced  dementia. 
Thus  one  subject  rambled  continuously  upon  his  "  thousands  of 
champagne,  hundreds  of  thousands  of  cigars,  and  his  five  hundred 
sons  and  daughters."  The  aspect  of  the  patient  corresponds  to  the 
mental  state ;  it  is  usually  one  of  gloomy  dejection  or  querulous  dis- 
content,  in  which  the  vacuous  expression  of  dementia  is  apparent; 

the  brow  is  often  corrugated  from  the  persistent  frontal  head- 
ache so  frequent  here,  and  the  hair  is  often  rubbed  ofi"  the  frontal 
region,  or  off"  the  whole  of  one  side  of  the  head,  by  the  patient's  hands; 
the  skin  is  swarthy  or  earthy  in  tint;  there  is  always  a  notable 
degree  of  atonicity  in  the  facial  muscles,  and,  indeed,  throughout 
the  musculature  of  the  limbs.  Upon  the  least  excitement  tremors 
of  the  facial  muscles  are  induced,  but  no  twitching;  the  lips  parti- 
cipate in  the  same  unsteadiness,  and  the  tongue  exhibits  a  fine  fibrillar 
tremor;  speech  is  impaired,  articulation  being  slowed,  or  blurred 
and  thick,  or  a  little  quivering;  it  is  never  explosive.  The  oculo- 
motor symptoms  characteristic  of  general  paralysis  were  present  in 
all  the  cases  observed  bv  us. 


522  PATHOLOGICAL    AKATOMV    OK    EPILEPTIC    INSANITY. 


PATHOLOGY   OF   EPILEPSY. 

Contents. — Modern  View  of  its  Nature — An  Impalpable  Trophic  Change— Objections 
to  Methods  of  Examination — Change  in  Elements  of  the  Second  Cortical  Layer 
— Fatty  Ciiange  in  Nuclei  of  Nerve-Cell — Common  also  to  Alcoholic  Insanity — 
Vacuolation  of  Nucleus — Ultimate  Break-down  of  Nerve-cell — Implication  of 
Motor-Cells- -Absence  of  Vascular  Implication — Functional  Endowments  of 
Nucleus — Resistance  of  Cell  to  Discharge — Nutritional  lihythm— Significance  of 
Size  of  Cell  and  Nucleus — Primitive  Type  of  Nerve-cell — Degraded  Type  of 
Nerve-cell — Cell-couformation  as  indicative  of  a  Convulsive  Constitution. 

The  morl)icl  histology  of  epilepsy  is  confessedly  an  obscure  question 
if  we  confine  our  attention  to  those  seizures  in  which  coarse  brain- 
disease  and  naked-eye  changes  are  not  appreciable.  Only  recently 
Ave  have  the  authority  of  Dr.  Gowers  to  the  effect  that  there  is  little 
likelihood  at  present  of  our  knowledge  of  its  pathological  nature 
becoinincr  more  definite,  and  that — "  The  chanjces  in  the  nerve-centres 
are  jDrobably  of  that  fine  kind  which  is  revealed  only  by  altered  func- 
tion, and  elude  the  most  minute  research."  There  exists  a  wide- 
spread community  of  opinion  that  the  pathological  anatomy  of  epilepsy, 
whatever  it  be,  is  the  expression  of  a  grave  nutritional  disturbance  of 
cell-protoplasm,  a  nutritive  disturbance  which  need  not  express 
itself  in  palpable  morbid  change  even  to  the  higher  powers  of  the 
microscope.  From  this  opinion,  however,  we  must  dissent ;  for  it 
appears  to  us  that  a  morbid  appearance  of  the  cortical  cell  does  exist 
of  a  highly-characteristic  nature,  when  the  cortex  is  the  subject  of 
careful  examination  by  t\\e  fresh  methods  of  research. 

Nor  does  it  appear  strange  that  the  morbid  change  alluded  to  has 
been  overlooked,  since  the  usual  methods  of  preparation  are  often  the 
least  adapted  for  revealing  it ;  the  chrome  salts  subjecting  the  cell  to 
very  important  alterations  which  obscure  the  actual  state.  In  the  first 
place,  the  nervous  elements  of  the  cortex  involved  are  the  smallest 
met  with  ;  and,  in  themselves,  are  not  the  most  clearly  demonstrable 
in  a  state  of  health.  Again,  attention  is  likely  to  be  distracted  by  the 
less-important  changes  in  cells  of  greater  magnitude,  where  morbid 
appearances  are  more  pronounced  features.  In  the  next  place,  the 
tissue-staining  is  liable  to  obscure  the  early  appearance  of  disease 
unless  cautiously  performed,  and  more  especially  the  employment  of 
osmic  acid  of  too  high  a  percentage,  or  for  too  prolonged  an  action. 

The  change  in  the  cell  alluded  to  is  not  peculiar  to  epilepsy  ;  it 
occurs  in  other  diseases,  and  especially  alcoholic  brain-disease,  but 
never  to  so  marked  a  degree  and  limited  to  such  special  cortical  areas 
as  in  epileptic  insanity.  The  nerve-elements  are  not  the  only  ones  to 
present  morbid  implication,  for  the  connective-element  or  neuroglia  is, 
as  long  known,  invariably  in  excess  of  the  normal.     To  describe  the 


CHANGES    IN    NUCLEUS   OF    NERVE-CELL.  523 

nerve  lesion  first.  The  small  irregularly-shaped  nerve-cells,  occupying 
the  position  of  the  second  layer  of  the  cortex,  exhibit  a  degenerative 
change  which  is  so  far  peculiar  that  the  nucleus  of  the  cell  is  the 
earliest  portion  affected  ;  the  cell-protoplasm  being  apparently  second- 
arily involved.  The  centre  of  the  nucleus  is  occupied  by  an 
extremely-bright,  highly-refractile,  spherical  Ijody — obviously  of  a /a^^y 
nature.  If  the  cell  be  stained  by  the  aniline  blue-black  the  morbid 
body  appears  as  an  unstained  bright,  spherical  bead  in  the  centre  of  the 
deep  blue-black  nucleus ;  the  cell-protoplasm  around  being  in  its  place 
differentiated  by  its  lighter  staining.  In  many  of  the  surrounding 
cells  no  further  change  may  be  observed  ;  but,  closer  observation  shows 
that  either  the  refractile  body  has  increased  so  as  to  occupy  the 
whole  available  space  in  the  nucleus,  the  boundaries  of  w-hich  are  still 
mapped-out  by  a  deep-stained  circle,  or  that  two  or  more  of  such 
bright  refractile  bodies  present  themselves  within  the  nucleus,  or  that 
the  nucleus  itself  is  no  longer  apparent  within  the  cell,  the  highly 
refractile  body  (in  size  and  outline  like  the  nucleus)  being  its  presumed 
representative  {PI.  xi.,  B.). 

Although  the  more  usual  aspect  presented  is  that  of  a  bright 
spherical  droplet  of  oil,  it  is  by  no  means  invariably  spherical,  but 
may  assume  a  crescentic,  oblong,  or  irregular  contour.  Minute  as 
these  nerve-cells  are,  the  strong  contrast  established  betwixt  the 
bright  lusti'ous  centre  and  the  deep  blue-black  aniline  stain  of  the 
surrounding  nucleus,  renders  the  change  so  distinct  that,  when  once 
the  attention  is  directed  to  it,  a  1-inch  objective  suffices  to  reveal  it 
readily  as  a  wide-spread  change  in  the  series  of  the  second  cortical 
layer  of  cells.  It  is  not  here  assumed  that  cells  in  other  layers  wholly 
escape  a  similar  implication,  but  that,  whilst  such  a  nuclear  change 
may  be  detected  here  and  there  in  the  small  and  large  pyramidal  cells 
of  the  succeeding  layer,  it  is  not  an  exceptional,  but  a  most  fi-equent, 
or  universal,  change  in  the  second  layer  of  the  cortex;  often  every  cell 
within  a  large  field  still  retaining  its  nucleus,  is  seen  flashed  within  by 
this  bright  morbid  spectrum  {PL  xi.,  B.).  When  the  change  has  pro- 
gressed so  far  that  one-half  of  the  nucleus  is  occupied  by  the  morbid 
substance,  the  former  appears  to  have  lost  its  selective  capacity  for  the 
aniline  reagent,  stains  poorly,  and  is  but  faintly  differentiated  from  the 
enclosing  cell ;  and,  as  the  fatty  change  proceeds,  any  remaining  nuclear 
mass  presents  so  delicate  a  stippled  shading  that  it  fades  ofi'  into  tlie 
cell-protoplasm,  and  is  with  difficulty  distinguished  therefrom,  or  is 
wholly  lost  to  view.  It  is  interesting  to  observe  the  persistence 
shown  by  the  nerve-cell  despite  the  degenerative  change  in  its  nucleus, 
and  it  is  only  later  on  in  the  stage  of  dissolution  that  the  cell-proto- 
plasm betrays  evidence   of  degeneration.      That  the  cells  ultimately 


524  IWTIIOLOGICAL    ANATOMY    OF    EPILEPTIC    INSANITY. 

break-down  is  sufficicnitly  evidenced  by  the  paucity  of  elements  in  this 
layer  contrasted  with  wliat  is  seen  in  the  healthy  brain,  and  by  the 
abundance  of  fragmentary  residue  left  ]>y  the  process  of  disintegration 
at  this  level  of  the  cortex. 

The  more  advanced  stage  of  this  fatty  nuclear  change  reveals  a 
VaCUOlatGd  condition  of  the  cell,  which  becomes  even  a  more  striking 
feature  tlian  the  simple  fatty  change.  This  vacuolation  is  evidently 
attributable  to  the  bursting  out  from  the  cell  of  the  globular  bead  of 
fatty  substance,  leaving  the  cavity  containing  it  as  a  very  conspicuous 
object  of  sharp-cut  marginal  contour.  Usually  the  cell  maintains  its 
original  contour,  whilst  a  large  cavity  occupies  its  centre,  as  large  as 
is  consistent  with  the  capacity  of  the  cell,  so  that  a  perfectly  spherical 
outline  is  maintained  within  an  angular  or  pyramidal  boundary,  the 
merest  rim  of  stained  protoplasm  (thickest  where  the  processes  emerge) 
bounding  this  cortical  vacuole  (PL  xii.).  At  times  the  escape  of  these 
contents  involves  a  large  margin  of  the  cell,  rupturing  and  destroying 
its  lateral,  or  its  basal,  periphery ;  still  the  remaining  protoplasm  else- 
where maintains  a  rigid  skeleton  of  the  original  cell,  so  that  little  real 
distortion  of  the  less-affected  portion  of  the  cell  exists.  The  evidence 
of  morbid  change  in  the  surrounding  protoplasm  of  the  cell  exists  not 
only  in  the  rigid  retention  of  the  form  of  the  enclosed  cavity,  but  also 
in  the  presence  of  pale  spots  indicating  the  degeneration  of  its  mass, 
which  are,  however,  of  far  less  lustrous  aspect  than  the  nuclear 
contents.  Scattered  amongst  the  less-diseased  cells  of  this  layer  we 
find  angular  fragments  of  destroyed  nerve-elements,  or  sheaves  of 
apical  processes  completely  dissevered  from  any  relict  of  cellular 
structure.  This  extreme  degree  of  change,  now  described  as  vacuola- 
tion of  the  cell,  may  occupy  the  whole  of  the  second  layer  of  the 
cortex;  but,  in  certain  cases,  it  has  been  found  to  affect  every  layer 
down  to  the  spindle-series  of  cells  inclusive.  When  the  larger  cells  are 
the  subject  of  this  change,  the  cell-protoplasm  presents  aggregated 
globules  of  morbid  material,  obscured  by  the  deeper  staining  of 
healthier  protoplasm ;  yet,  pale  by  contrast,  it  gives  the  cell  a  peculiar 
rugged  mulberry-like  aspect. 

The  large  "  ganglionic  "  cells  suffer  very  unequally  in  different  sub- 
jects and  at  different  sites.  In  early  stages  of  implication  they  appear 
swollen,  and  take  up  an  intense  staining  of  their  protoplasm,  so  as  to 
obscure  their  contents  in  aniline  blue-black  preparations.  Such  cells, 
in  mounted  preparations  present  an  unusual  relief,  with  clear-cut 
contour,  very  unlike  the  same  cell  in  a  further  advanced  stage  of 
degeneration,  and  are  much  more  sharply  defined  in  this  state  than  in 
health  (Fl.  xii.,  deeper  layer).  Pigmentary  degeneration  of  a  limited 
portion  of  the  cell  may  be  seen,  whilst  in  the  darkly-stained  protoplasm 


EXTENSIVE    VACUOLATION    OF    NUCLEI.  525 

three  or  four  paler  spots  are  seen,  somewhat  refVactile  and  gleaming 
through  the  superimposed  protoplasm.  Many  of  such  large  cells  are 
swollen  and  globose,  maintain  their  lateral  and  basal  processes,  Ijut 
have  no  apical  process,  or  merely  a  stunted  one  attached  ;  they  are 
uniformly  stained  of  a  pale  tint  throughout,  the  nucleus  having  dis- 
appeared. When  still  further  degenerated  these  cells  present  a  blurred 
outline,  as  if  from  fatty  liquefaction  of  their  contents;  or  an  extremely 
faint  ghost-like  representative  of  the  cell  alone  remains. 

With  this  fatty,  nuclear  change  and  vacuolation  of  the  cells  of  the 
superficial  cortical  layer,  we  observe  no  associated  vascular  change ; 
the  vessels  may  be  somewhat  coarse,  and  distended  more  than  usual, 
but  no  extreme  alteration  is  observable  in  the  tunics  of  the  vessel,  of 
course  excepting  such  as  may  be  attributable  to  other  agencies,  such  as 
the  senile  or  alcoholic  degenerations,  or  the  complication  of  tubercle  or 
of  syphilis.  Nuclear  proliferation  along  the  adventitia  is  rarely  seen 
in  epileptic  insanity.  In  like  manner,  we  do  not  meet  with  the 
presence  of  sjnder-cells,  which  permeate  the  cortex  and  medulla  where 
vascular  lesions  afi'ecting  the  blood  and  lymph-channels  prevail.  Thus, 
in  the  morbid  anatomy  of  epileptic  insanity  we  find  a  special  freedom 
from  nuclear  proliferation,  from  vascular  degeneration,  and  from 
hypertrophic  states  of  the  lymph-connective  system,  which  obtrude 
themselves  in  alcoholic  cases  and  in  the  subjects  of  general  pai^alysis. 

Patholog'y. — The  essential  nature  of  epilepsy  is  that  of  an  abnormal 
discharge  of  nerve-force  from  the  higher  cerebral  centres  in  the  cortex, 
an  "  occasional,  sudden,  rapid,  and  excessive  discharge  "  {Dr.  Htighlings- 
Jackson).  It  matters  not,  for  the  essential  character  of  this  afliection, 
whether  the  phenomena  are  sensorial  almost  exclusively  or  motoiial, 
whether  the  sphere  of  mind  is  specially  involved,  or  whether  there  is 
the  fullest  development  of  the  epileptic  spasm;  the  essence  of  the 
disease  consists  in  this  excessive  local  discharge.'"  A  nutritive  irrita- 
bility underlies  the  morbid  activity,  and  invariably  expresses  itself  in 
some  one  or  other  morbid  change  recognisable  in  the  structural 
elements  of  the  cortex.  As  we  have  seen  in  such  cases  of  epilepsy, 
where  mental  disturbance  predominates  and  actual  insanity  co-exists, 
we  have  a  notable  affection  of  a  special  series  of  cells,  not  exclusively 
seen,  however,  in  this  disease,  for  it  likewise  prevails  in  other  con- 
vulsive afi'ections,  such  as  chronic  alcoholism  wherein  spasmodic 
discharges  of  nerve-energy  are  frequent. 

The  extensive  nuclear  degenerations  which  we  have  described  must 
issue  in  the  death  of  the  cell.     We  know  little,  for  certainty,  as  to  the 

*  Ou  the  origin,  essential  uatiire,  ami  conditioning  factors  of  the  nervous  dis- 
charge, see  a  masterly  analysis  in  Dr.  Charles  Mercier's  recent  work — IVie  Mei'vous 
System  and  the  Mind. 


526  PATHOLOGICAL    ANATOMY    OF    EPILEPTIC    INSANITY. 

functional  endowments  of  the  nucleus,  but  we  may  recognise  its  presence 
in  all  conditions  of  active  growth  and  functional  life  in  the  cell,  whether 
it  be  a  nerve-cell  or  element  of  other  tissues,  including  the  phenomena 
of  karyokinesis.  With  its  atrophy  and  disappearance  we  find  associated 
declining  functional  activity  and  ultimate  degeneration  of  the  cell 
itself.  We  have  seen  elsewhere  that  there  is  much  reason  for  re- 
garding the  cells  which  prevail  in  this  layer  of  the  cortex,  as  per- 
taining to  this  sensory  type  of  nerve-element,  and  that  an  organic 
connection  subsists  betwixt  them  and  the  large  motor  elements  dis- 
tributed at  a  lower  level ;  in  fact  we  may,  perhaps,  regard  these 
individual  layers  as  constituting  a  highly-complex  sensory-motor  arc, 
of  which  they  are  the  respective  poles.  What  is  the  functional 
relationship  existing  between  these  elements  ?  That  these  presumed 
sensory  units  have  an  inhibitory  control  over  the  subjacent  elements, 
and  that,  lacking  such  control,  their  discharge  will  be  subjected  to  the 
periodicity  of  the  nutritive  rhythm  is  very  probable.  The  changes 
presented  by  the  cortical  nerve-cells  have  long  led  us  to  regard  the 
nucleus  as  subserving  an  important  role  in  the  functional  activity  of 
the  cell ;  that  its  displacements,  distortion,  degeneration,  enfeebled 
vitality,*  and  its  absence  are  constant  accompaniments  of  cerebral 
disturbances  characterised  by  loss  of  inhibitory  control.^ 

From  this  point  of  view,  we  have  been  accustomed  to  regard  the 
proportionate  size  of  nucleus  to  nerve-cell  as  indicative  of  the  inhibitory 
controlling  capacity  of  the  cell  in  question — its  own  resistance  to  dis- 
charge. Hence,  these  minute  elements  with  large  nuclei  in  the  second 
layer  would  possess  a  far  higher  degree  of  resistance  to  nervous  discharge 
than  those  of  lower  levels,  in  which  the  nucleus  bears  a  far  smaller 
ratio  to  the  surrounding  cell-mass.  Thus  in  these  higher  levels  nerve- 
discharge  would  be  impeded,  and  the  resistance  and  time-element  charact- 
eristic of  the  mental  operations  would  come  into  play.  Certain  it  is 
that  in  such  cases  whei'e  nuclear  degeneration  has  proceeded  far  in  this 
layer,  there  is  a  motor  and  mental  instability  characterised  especially 
by  periods  of  nutritional  rhythm.  In  like  manner,  the  cells  of  the 
motor  area  are  proportionately  large,  and  subserve  the  function  of 
storage  of  motor   energy ;  but  their   nucleus  is  small   in  proportion 

*  As  probably  ilhistrated  in  its  feeble  staining  to  usual  reagents. 

t  Nor  is  this  supposition  opposed  to  the  results  of  Kussniaul  and  Tenner  upon 
the  effects  of  sudden  loss  of  large  quantities  of  blood.  Suddenly-induced  anaemia 
hy  withdrawing  the  requisite  pabulum  would  directly  affect  the  nuclear  centres  of 
cell-life,  which  are  recognised  as  actively  operative  in  the  nutrition  of  the  cell ; 
the  withdrawal  of  such  pabulum  would  be  equivalent  to  a  total  arrest  of  such 
function,  to  the  virtual  paralysis  resulting  in  the  discharge  of  nerve-energy  from 
the  cell  expressed,  on  the  mental  side  in  loss  of  consciousness,  and  on  the  physical 
side  in  general  convulsions. 


THE    MORBID    NERVE-CELL    IN    EPILEPSY.  527 

thereto,  and  their  resistance  to  discharge  consequently  slight,  their 
functional  equilibrium  is  more  readily  affected ;  their  greater  mass 
requires  augmented  nutritive  resources  to  reinstate  them  subsequent 
to  their  discharge  (Ross). 

It  has  already  been  indicated  in  discussing  the  etiological  relation- 
ships of  epilepsy  that  heredity  plays  a  prominent  role,  and  that  epilepsy, 
direct  or  collateral,  occurs  in  a  large  proportion  of  cases;  with  these 
are  associated  ancestral  intemperance,  which  likewise  is  an  important 
factor.  It  becomes,  therefore,  a  question  worthy  of  consideration 
whether  we  have  here  to  recognise  in  the  structural  modification  of  the 
cell  the  physical  basis  of  such  hereditary  transmission;  is  it  probable 
that  the  nuclear  and  cellular  change  bears  the  imprint  of  ancestral 
vice?  That  the  inflated  spheroidal  cell  of  epileptic  idiots  is  a  distinct 
reversion  (or,  at  least,  an  undeveloped  stage)  is  doubtless  true;  not  only 
does  its  conformation  indicate  its  lowered  type;  its  degenerated  proto- 
plasm a  sustained  nutritional  anomaly;  its  paucity  of  branches  a 
restricted  relational  element  of  cell-life;  and  its  nuclear  change  in  form 
and  position  some  vital  peculiarity  inconsistent  with  the  normal 
activity  of  the  cell :  but  we  also  have  evidence  of  reversion  in  its  case, 
in  the  appearance  of  such  cells  {i.e.,  of  inflated  spheroidal  elements  with 
few  processes)  in  some  lower  forms  of  life,  and  we  have  elsewhere  indi- 
cated their  existence  as  a  normal  element  in  the  cortex  of  the  ape.* 
We  see  no  reason,  therefore,  for  doubting  that  when  such  cells  occur  in 
the  cortex  of  a  class  who  also  bear  the  history  of  ancestral  vices,  such  as 
epilepsy  and  drink,  that  it  is  the  expression  of  a  reversion  to  a  more 
primitive  type  so  induced. 

Here,  however,  we  must  distinguish  betwixt  idiopathic  epilepsy  in 
the  adult,  and  those  forms  which  are  clearly  due  to  gross  central 
change,  or  such  cases  where  epilepsy  is  but  the  accidental  accompani- 
ment of  developmental  arrest.  The  onset  of  epilepsy  in  early  life  is 
recognised  as  highly  ominous  to  the  mental  well-being,  and  it  is 
undoubtedly  an  established  fact  that,  although  in  adult  life  in 
exceptional  cases,  epileptic  seizures  may  co-exist  with  great  intellectual 
vigour,  yet  its  occurrence  during  periods  of  active  cerebral  develop- 
ment in  infancy  and  youth  is  attended  by  a  profound  change  in  such 
activities,  and  usually  in  their  total  arrest.  This  fact  is  often  expressed 
in  such  terms  as  to  imply  apparently  that  the  "fits" — i.e.,  the  convulsive 
seizures  themselves — are  the  agencies  whereby  the  cerebral  activities 
underlying  mental  evolution  are  injuriously  affected.  It  must,  how- 
ever, be  borne  in  mind  that  the  convulsive  discharge  in  itself  is  not  the 
factor  in  the  arrest,  but  simply  betrays  the  nutritional  impairment  (in 
itself  the  origin  of  the  convulsive  discharge,  and,  at  the  same  time, 
*   Trans.  Roy.  Soc,  he.  cit. 


528  PATHOLOGICAL    ANATOMY    OF    ALCOHOLISM. 

of  arrested  evolution).  It  is  in  the  structural  peculiarity  of  the  cell 
that  we  must  learn  to  recognise  the  origin  of  the  convulsion,  and 
of  the  stunted  mental  development  which  such  vicious  conformation 
symbolises. 

On  the  other  hand,  in  forms  of  idiopathic  epilepsy  arising  subsequent 
to  the  attainment  of  adult  life,  the  more  striking  feature  presented  to 
our  notice  is  the  degradation  of  mind — its  gradual  obnubilation  by 
progressive  dementia.  Are  we  prepared  to  recognise  such  distinction 
in  the  histological  elements  of  the  cortex?  We  think  there  can  be  but 
little  doubt  that  in  the  latter  cases  {dementia)  we  simply  witness  a 
degenerative  affection  of  the  nerve-cell,  which,  apart  from  this,  betrays 
evidence  of  a  full  developmental  constitution.  In  the  former  (epileptic 
idiocy),  however,  we  find  an  altered  type  of  cell,  a  limitation  of  its 
connecting  meshwork,  and  a  conformation  so  decided  as  to  at  once 
indicate  the  distinction.  Yet,  underlying  both  forms,  we  still  recognise 
that  disparity  betwixt  nucleus  and  protoplasm,  and  the  displacement 
or  degeneration  of  the  former,  which  to  us  appears  to  bespeak  a 
convulsive  constitution. 


PATHOLOGY  OF  CHRONIC  ALCOHOLISM. 

Contents. — Morbid  Change  iu  Cerebral  Vessels — Scavenger-Cells  in  Outer  Zone  of 
Cortex — Sclerosis  of  Outer  Zone — Amyloid  Bodies  beneath  Pia — Implication 
of  Motor  and  Spindle-Cells — Significance  of  these  Changes— Deepest  Layers 
more  generally  Involved — Early  Vascular  Implication— Aneurysmal  Bulgings — 
Atheromatous  and  Fatty  Change — Pigmentary  Degeneration  of  Motor  Cells — 
Scavenger-Elements  in  Spindle-Layer — Degeueratioa  of  MeduUated  Nerve- 
Fibre — Sx^inal  Lesions— Vascularity — Hypertrophy  of  Tunica  Muscularis  an 
Inconstant  Feature — Eelationships  to  Chronic  Bright's  Disease — Sclerosis  of 
White  Columns  of  Cord — Spinal  Degenerations  in  Ty^ncal  Case — Implication  of 
Clai'ke's  Column — Immunity  from  Multiple  Neuritis — Neurotic  Heritage — 
Chronic  Endarteritis— Fatty  and  Sclerous  Tendency — The  Brain  of  the  Criminal 
Class — Exceptional  Resemblance  to  General  Paralysis — Coincidence  of  Grandiose 
State  and  Delusions  of  Persecution — Inconstant  Vertical  Implication  of  Cord — 
Constitutional  State  that  of  Chronic  Bright's  Disease — Exceptional  Transition 
to  Genei-al  Paralysis — Significance  of  Arterial  Changes — Affection  of  the 
Visceral  System. 

The  vessels  dipping  into  the  cortex  from  the  pia  are  of  undue  size, 
coarse,  and  frequently  tortuous,  and  their  coats  are  in  advanced  stages 
of  atheromatous  and  fatty  change.  The  nuclei  of  the  adventitial  sheath 
are  somewhat  numerous,  are  freely  proliferating,  or  their  protoplasm  is 
in  a  state  of  fatty  disintegration  (PL  xvi..  Jigs.  1,  2).  Far  the  more 
prominent  feature,  however,  is  the  abundance  of  scavenger-cells  which 
pervades  the  upper  or  outermost  region  of  the  peripheral  zone  of  the 
cortex  lying  immediately    beneath  the  pia ;    these    nucleated   proto- 


Plate  XV: 


iall   ancjizLar    cells  of  4^^-^ lay tr  —-jk  «ifV)'l  ^cff^ 


PefwasculaT   izzzclei 
PeTtvasciilar  niiclei 


Moior   ISferve-cell    and ,.-■ 
its  mzt-riei'd  -■rescel 


■De^eneraiion   of  Apejc  process 

•:**     ti         7VeT-ire -ceZZ    zxncierqoiTiq 
-»,'•;■--•?»■ —  7         7  , .     -^ 

••     ^^       granuLar  cLe^ene-rcLZ-LOTL. 


'  J)LsecLsecL     OL-rie-riol&. 


Gr  an.iilaTr  iegener  aiioii  of  T>Ter"\re  -  cells  itl  fif-tli  lawyer  of 
IvToioir  Coi:te:K:  ^^itli  pirolif eTatioxL  of  peT#cell-u:lax  &-p>eri  = 
^asc"ulaT    TLitclei     in   a    case    of    Clironic    Alcoliolic  InsarLity. 

X  210  . 


SpxdeT   cells    p-rclxfe-raivno. 


\    iDngeTieratinj    Nerve-  cell 
*M.--"devoxd  ofmicleizs. 


)(\ 


^:^^^ 


FeriYascixlar'TaxcleL  crawdinc 
-Lvpon  irralls    of  hlood  vesset. 


Fii.2. 


J^-olifeTaizon.  of  _^ 

-nuclei    on  iii=       "      f] 
'■si-foTn-L  cells  \1 


Axieiari  sirtal    cliia  tation   of 
PeriA^ascular    sac. 
General  Paralysis. 
X  210.. 


Cftan^es  in   deepest  or  Spinile    cell   layer 
of    launxan     Cortege. 
Chronic   Alcoliolic  Insanity. 
xl80. 


T)aTiiel3S0TLik  Co,  sc-ilp . 


CHANGES    IN    OUTER    ZONE    OF    CORTEX.  52& 

plasmic  bodies  are  everywhere  seen,  their  branching  processes  forming 
a  dense  matting  which  converts  the  outermost  fourth  of  this  cortical 
layer  into  a  closely-felted  substance  of  minute  meshes,  the  aspect  of 
which  differs  strikingly  from  that  normal  to  this  region  {PL  ix.,Jig.  1). 
Whenever  a  blood-vessel  passes  downwards  through  the  cortical  layers, 
these  scavenger-cells  are  more  numerous,  following  the  line  of  vascular 
channelling,  and  so  dipping  down  into  the  nerve-elements  of  the 
second  layer.  The  appearance  forcibly  reminds  one  of  the  increase  of 
connective  passing  along  Grlisson's  capsule  in  a  sclerosic  state  of  the 
liver. 

This  felted  structure  is  always  most  dense  immediately  beneath  the 
pia,  where  it  is  so  far  condensed  as  to  take  a  deeper  staining  of  the 
reagent  quite  recognisable  to  the  naked  eye.  The  depth  of  the  whole 
peripheral  zone  is  also  perceptibly  diminished,  the  outer  fourth  being 
distinctly  mapped-off  from  the  rest  by  its  deeper  tinge.  We  meet 
with  this  development  in  different  stages;  occasionally  the  cellular 
element  predominates — young  scavenger-cells  are  numerous,  their  fine 
extensions  being  widely  scattered  and  sparse ;  in  other  cases  the  cells 
are  found  of  larger  size,  forming  plump,  amoeboid  elements,  from  which 
radiate  processes  pass  into  a  fine  meshwork  around ;  still  later,  the 
protoplasmic  masses  have  dwindled  down  or  totally  disappeared, 
leaving  simply  the  dense,  felted,  fibrous  structure  profusely  besprinkled 
with  the  still  remaining  nuclei  {PL  ix.,  /iff.  1).  Beneath  the  pia, 
betwixt  it  and  the  surface  of  the  cortex  in  the  so-called  eincerehral 
space,  we  often  find  a  vast'  quantity  of  amyloid  bodieS,  and  the  fact 
that  these  are  abundantly  recognisable  in  fresh  sections  from  frozen 
brain  is  a  sufficient  refutation  of  the  assumption  that  such  bodies  are 
not  of  morbid  nature,  but  artificial  products  of  alcoholic  reagents  used 
in  preparation.  Here  and  there  along  the  walls  of  a  blood-vessel  a 
little  heap  of  proliferating  nuclei  is  seen,  from  which  fibrous  extensions 
pervade  the  cortex  on  all  sides,  giving  the  vessel  a  peculiar  spinous 
aspect. 

The  perivascular  space  is  also  seen  distended  by  numerous  lymphoid 
elements,  and  the  nuclei  of  the  sheath  are  often  mapped-out  by  a 
linear  series  of  oil-globules  which  alone  remain  to  represent  the 
degenerated  element.  Critically  examining  the  second  and  third 
layers  of  the  cortex,  we  find  no  very  prominent  lesion — a  few  of  the 
lower  pyramidal  cells  may  be  degenerate — but,  until  we  reach  the  fifth 
layer  of  motor  cells,  no  very  obvious  change  is  apparent  in  most  cases 
{PL  xyl,flcj.  1). 

These  large  cells,  however,  are  in  an  advanced  stage  of  fatty  change, 
and  together  with  the  layer  of  spindle-cells  immediately  beneath,  are 
undergoing  extensive  disintegration  and  absorption  {PL  xvi.,  fig.  2). 

34 


■530  PATHOLOGICAL    ANATOMY    OF    ALCOHOLISM. 

Can  we  explain  this  apparent  anomaly  of  the  escape  of  the  superjacent 
layers  of  nerve-cells,  and  the  extensive  implication  of  the  outermost 
and  deepest  layers  betwixt  which  they  lie  ?  A  special  selection  of 
certain  layers  by  the  morbid  process  appears  to  be  evident  here ;  and 
may  be  a  fact  of  great  significance. 

In  the  first  place,  we  must  call  to  mind  the  fact,  that  the  outermost 
cortical  layer  represents  the  apical  distribution  of  the  large,  deep- 
seated  cells  which  have  been  presumed  to  possess  motor  endowments  ; 
and  that  their  poles,  therefore,  are  (in  the  early  stage  of  general 
paralysis,  as  well  as  in  alcoholism)  affected  by  the  sclerosic  change 
proceeding  in  the  outer  layer  of  the  cortex,  and  that  these  cells  are, 
therefore,  affected  by  a  degenerative  change  ere  the  morbid  process 
extends  deeply  into  the  small  elements  of  the  second  and  third  layers. 
But  simultaneously  with  this  an  invasion  of  cortical-elements  also 
takes  place  from  below — i.e.,  from  the  medulla  of  the  gyri,  and  this 
morbid  process  spreading  upwards  involves  both  spindle  and  motor 
elements  successively. 

The  cerebral  cortex  presents,  therefore,  in  such  cases  very  notable 
morbid  change ;  and  one  specially  characterised  by  the  greater 
concentration  of  the  lesion  in  motor  realms  of  the  hemisphere,  as  well 
as  by  a  somewhat  definite  restriction  to  certain  layers  of  the  cortex,  to 
the  exclusion,  more  or  less,  of  the  other  layers.  The  deepest 
cortical  layers  are  those  more  especially  affected ;  cases  being  met 
with  where  the  uppermost  layers  show  no  morbid  indications 
whatsoever. 

The  vascular,  nei"vou3,  and  connective  elements  all  participate  in 
the  change,  and  it  thus  becomes  of  interest  to  learn  which  of  these 
tissues  is  primarily  involved  and,  therefore,  plays  the  more  important 
role  in  establishing  the  pathogenesis  of  chronic  alcoholic  insanity.  A 
careful  study  of  a  series  of  such  cases  would  lead  one  to  infer  that  the 
vascular  is  the  first  tissue  involved  in  the  morbid  evolution.  The 
long,  straight  vessels  of  the  cortex  are  peculiarly  liable  to  these 
changes,  and  where  they  dip  down  deep  into  the  spindle-series  of  cells, 
such  vessels  present  gross  lesions  of  their  tissues,  as  also  of  the 
immediate  neighbourhood  around. 

The  vessels  themselves  are  enormously  and  unequally  distended, 
showing  numerous  ampullae  or  aneurysmal  distensions,  usually  fusiform 
in  character,  their  tunics  crowded  with  nuclear  proliferation.  Care- 
fully-prepared sections  of  frozen  cortex  often  appear  riddled  by  a  large 
number  of  circular  holes,  with  sharp-cut  edges,  as  if  punched  out  of  the 
brain-tissue;  or  by  long  fusiform  channels,  the  site  of  diseased  vessels 
which  may  have  dropped  out ;  or  still  convey  distended  vessels,  the 
walls  of  which  are  mottled  by  atheromatous  change,  whilst  a  peculiar 


IMPLICATION   OF   NERVE-CELLS.  531 

albuminoid    material    (unstained    by  aniline)   fills   their  cavity  or  is 
effused  around  their  ruptured  orifices.      The   nervous,  as  well  as  the 
connective,  elements  of  the  upper  three  or  four  layers  of  the  cortex 
may  exhibit  no  morbid  change,  but  at  the  site  of  the  large,  so-called 
motor  cells,  constituting  the  clustered  groups  of  the  central  gyri,  we 
discover   a   notable   degeneration.      These    great   nerve-elements   are 
much   swollen  and   rounded   in  contour,  and,  in  lieu   of  their  usual 
extremely  delicate  protoplasm,  present  a  rough  granular  aspect  inter- 
nally, which  often  takes  an  intense  staining  from   aniline,  leaving  a 
portion,  however,  quite  unaffected  by  the  reagent  and  of  a  coarsely 
granular  and  often  yellowish  hue  {PI.  xvi.,  fig.   1).      Such  cells  are 
frequently    seen    deprived    of  their   apical    processes    by    a    veritable 
degeneration.     At   its    connection    with    the    cell   itself   this    process 
may    be    greatly    and    irregularly    swollen    and    pigmented,    beyond 
which    a    sudden    attenuation  occurs,  and,  after  a  slightly-contorted 
course,  it  disappears  entirely  (see  several  instances  in  PI.  x.yi.,fig.  1). 
Another  appearance  universally  presented  by  these  degenerate  cells  is 
the  abnormal,  coarsely-defined  boundary-wall  of  the  cell,  which,  as  we 
know,  does  not  exist  as  a  separate  constituent  in  the  normal  cell  of 
health,  or,  at  all  events,  cannot  be  difierentiated  from  the  protoplasmic 
contents  in  fresh-prepared  sections  from  frozen  cortex.     The  formation 
of  this  cell-wall,  betwixt  which  and  the  enclosed  protoplasm  a  mass  of 
pigment  collects,  the  former  shrinking  as  the  latter  encroaches  upon  the 
cell-contents,  is  a  constant  feature  in  all  cases  of  alcoholic  degeneration 
of  the  cortex ;  it  brings  the  cell  into  a  peculiarly  notable  relief,  which 
is  observed  in  other  degenerative  affections  of  the  cortex.     These  large 
degenerate   cells    have   usually    several    short,    stunted,    and    swollen 
processes  to  which  nuclei  adhere.     Three-fourths  of  their  cavity  may 
be    occupied    by   coarse,   granular,    golden  pigment,   and    the    stained 
protoplasmic  residue  exhibit  a  few  glistening  refractile  oil-globules,  or 
one  large  circular  cavity  (vacuole),  from  which   such  oil-globules  have 
forced  their  way  out,  the  protoplasm  in  such  a  case  not  filling  the 
vacuum. 

Down  in  the  lowest  layer  of  the  series — the  spindle-cell  formation — 
we  come  suddenly  upon  large  developments  of  scavenger-cells,  which 
above  this  level  were  not  apparent.  Such  elements,  characterised  by 
their  spider-like  appearance,  are  scattered  profusely  upon  the  coarse 
blood-vessels  of  this  region  (above  referred  to),  and  extend  their  rami- 
fying processes  in  all  directions  around  (PL  xyL,  fig.  2).  The  spindle-cells, 
moreover,  are  themselves  covered  by  heaps  of  nuclear  proliferations 
which  often  entirely  conceal  them  from  view,  so  that  their  position 
and  course  are  usually  mapped-out  and  alone  indicated  by  these  little 
nuclear  accumulations.     One  is  also  struck  by  their  greatly  diminished 


532  PATHOLOGICAL    ANATOMY    OF    ALCOHOLISM. 

number,  and  by  their  frequent  pigmentary  change  where  the  cell- 
contents  are  visible.  The  conclusion  forced  upon  us  by  the  appear- 
ances presented  is  that  they  are  undergoing  rapid  degeneration  and 
removal  through  the  agency  of  the  scavenger-corpuscles,  which,  as 
previously  explained,  act  in  the  capacity  of  "phagocytes,"  and  devour 
the  nerve-elements.  In  PL  :x.Yi.,Jig.  1,  representing  the  large  motor 
cells,  we  observe  three  large  elements  with  truncated  summits  under- 
going marked  degeneration.  Above,  there  is  a  similar  cell,  in  which 
the  greater  part  of  the  apical  process  is  pigmented  yellow,  whilst  at 
its  base  a  coarse  vessel,  crowded  with  a  heap  of  nuclei,  is  seen. 
Many  small  cells  are  also  scattered  about,  covered  with  a  rich  nuclear 
proliferation.  In  fig.  2,  which  represents  the  same  cortex  but  at  a 
lower  level,  the  spindle-cell  formation  is  seen,  sparsely  scattered  with 
nuclei,  but  the  site  of  a  rich  colony  of  scavenger-corpuscles.  The 
paucity  of  the  spindle-cells,  which,  at  this  site,  should  be  most  abun- 
dant, is  well  seen  in  contrast  with  a  section  taken  from  sensory  realms 
where  scavenger-cells  are  not  formed  (to  the  right  and  below  in  fig.  2)  ; 
the  cells  are  not  pigmented,  but  are  covered  with  nuclei.  The  basal  or 
axis-cylinder  process  of  these  large  motor  cells  is  a  very  persistent  struc- 
ture in  most  degenerative  aff"ections  of  the  nerve-cell ;  and,  as  we  have 
seen,  whilst  the  apical  process  readily  breaks  down  and  degenerates  at 
an  early  stage,  we  yet  find  that  this  axis-cylinder  process  jiersists.  If, 
however,  the  medullated  nerve-fibres  passing  up  from  the  medullary  core 
of  the  gyrus  into  these  lower  regions  of  the  cortex  be  examined,  a  very 
striking  change  is  apparent.  In  fresh  sections  of  healthy  bi-ain  these 
fibres  are  not  stained  by  the  aniline  method ;  the  medullated  sheath 
prevents  the  reagent  gaining  access  to  the  axis-cylinder.  In  certain 
degenerative  conditions,  however,  a  change  occurs  in  the  medullary 
investment,  probably  of  a  fatty  nature.  The  medulla  is  removed  or 
greatly  attenuated,  so  that  the  axis  is  exposed  and  stained  readily  by 
this  reagent,  and  then  it  is  apparent  that  the  axis-cylinder  is  itself 
greatly  swollen  and  often  irregularly  fusiform.  The  identical  appear- 
ance is  also  observed  in  senile  decay  of  the  cortex,  and  here  often 
to  a  much  more  striking  degree  than  in  alcoholics.  Upon  the  medul- 
lated investment,  where  it  appears,  spider-cells  are  often  seen  abun- 
dantly ramifying.  The  medulla  of  the  convolutions  in  cases  of  chronic 
alcoholism,  therefore,  presents  very  notable  divergence  from  the  normal 
appearance,  which  at  once  arrests  the  attention  in  preparations  of  fresh 
brain,  stained  by  the  aniline  methods,  the  straight  axis-cylinders  being 
prominent  objects  crowding  the  field  in  bundles  which  can  be  traced 
for  great  distances  through  the  medulla. 

On  scanning  the   white  matter,  we   are   also   struck   by  the  large 
number  of  extremely  coarse  dilated  vessels,  which  afibrd  us  evidence 


VASCULAR    LESIONS — SPINAL    IMPLICATION.  533 

also  of  grave  structural  change.  These  nutrient  twigs  are  not  only 
generally  dilated,  but  present  along  their  course  frequent  fusiform  and 
sacculated  aneurysmal  distensions,  often  of  large  size,  the  coats  of  which 
are  notably  diseased.  These  aneurysmal  sacs  in  many  cases  will  have 
fallen  out  of  the  section,  giving  rise,  as  described  in  the  cortex 
above,  to  clean-cut  circular  or  fusiform  openings,  which  are  often  very 
numerous  in  such  subjects.  The  sacculated  dilatation  is  often  the  site 
of  a  large  accumulation  of  hsematoidine  granules  which  crowd  its 
interior,  and  are  scattered  profusely  over  its  surface.  Occasionally  the 
vessel  is  seen  plugged  (possibly  by  a  fatty  embolus) ;  the  proximal 
distended  part  may  have  ruptured,  extravasated  blood  and  hsemato- 
idine  crystals  crowding  the  field  around;  or  a  more  frequent  appearance 
(seen,  in  fact,  universally  over  the  field)  is  the  distended  vessel  with 
the  intima  in  a  state  of  atheromatous  and  fatty  Chang'G,  and  the 
nucleated  element  of  the  sheath  also  undergoing  fatty  disintegration  ; 
the  walls  covered  with  young*  spideP-CellS,  and  bristling  with  their 
processes  on  either  side  (PL  x.Yi.,fig.  2). 

Large  patches  of  fatty  material  containing  oil-globules  and  granules 
are  seen  along  the  coats  of  the  blood-vessels,  in  fresh-stained  aniline 
preparations.  As  unstained,  colourless,  and  highly  refractile  spots, 
contrasting  with  the  healthier  and  stained  tunics  around,  such  patches 
have  a  swollen,  semi-opaque  aspect.  All  the  more  degenerate  nutrient 
twigs  are  the  site  of  a  rich  colony  of  scavenger-cells  in  their  various 
phases  of  development  and  retrogression ;  such  elements  often  look 
like  simple  nuclei,  until,  carefully  focussed,  their  delicate  protoplasmic 
mass  and  radiating  processes  are  discerned.  These  scavenger-elements 
are  traced  in  great  abundance  throughovit  the  white  matter  of  the 
convolutions. 

Plugged  vessels,  also,  appear  frequently ;  the  tissue  on  either  side 
being  often  deep-stained  and  sclerous  in  character,  and  the  axis- 
cylinder  in  the  neighbourhood  unduly  large  and  ii-regularly  swollen. 
The  medulla  shows  a  patchy  staining  of  its  ground-work  to  low  powers, 
which  on  the  use  of  higher  objectives  is  resolved  into  light,  unstained 
areas  having  few  or  no  nuclei,  and  darker  stained  areas  of  a  fine- 
punctated  aspect  (the  result  of  fibrillated  spider-cells),  amongst  which 
are  many  nuclei. 

Spinal  Cord. — Throughout  the  whole  extent  of  the  spinal  cord  we 
find  increased  vascularity  or,  at  least,  a  more  obtrusive  presentation  of 
vessels  than  is  normally  observed  here.  The  vessels  supplying  the 
posterior  columns  are  those  most  afiected,  those  of  the  anterior 
columns  least  involved,  whilst  the  lateral  tracts  suffer  almost  as 
frequently  as  the  posterior.  These  nutrient  branches  become  pro- 
minent objects  by  reason   of  the   great  increase  in  the  thickness  of 


534  PATHOLOGICAL  ANATOMY  OP  ALCOHOLISM. 

their  walls ;  a  feature  which  is  exceptionally  striking  with  respect 
to  the  smaller  vessels  between  4  /x  and  8  /i  in  diameter,  the  open 
lumen  of  such  divided  vessels  rarely  being  over  one-third  or  one- 
fourth  the  whole  dia^meter;  but  vessels  measuring  respectively  18  /x 
and  36  /i  across  also  have  not  infrequently  a  lumen  of  but  5  /x  to  10  /i. 
This  increase  in  thickness  is  seen  to  be  due  entirely  to  their  muscular 
coat,  which  in  small  vessels  of  8  /a,  diameter  will  attain  the  thickness  of 
2  (h.  The  increase  in  the  muSCUlariS  encroaches  much  upon  the 
cavity  of  the  vessel  itself,  and  the  non-elastic  intima  is  conse- 
quently thrown  into  a  plaited  form,  or  has  a  condensed  deeply-stained 
appearance  mapping  it  off  from  the  tunica  media  ;  occasionally,  the 
vessel  is  occluded  by  this  increase  in  its  muscular  tunic. 

It  is  not  all  cases  of  alcoholism  that  exhibit  this  notable  thickening 
of  the  muscularis  ;  for  in  some  we  observe  far  less  concentration  of  the 
disease  upon  the  vascular  supply  of  the  cord  than  upon  the  vessels  of 
the  cerebral  cortex.  The  following  averages  represent  very  conclu- 
sively the  dimensions  of  the  lumen  relatively  to  those  of  the  arterial 
tunics  in  cases  where  spinal  symptoms  were  a  notable  feature,  as  con- 
trasted with  those  in  which  no  special  symptoms  presented  them- 
selves : — 

Vessels  in  Chronic  Alcoholic  Insanity. 

Presenting  Spinal  Symptoms.  i  Cases  Devoid  of  Spinal  Symptoms. 

Whole  Diameter  of  I         Diameter  of 

Vessel.  Lmnen.  VesseL  Lumen. 


18 /u  5  m 

27  /x  9  M 

37  /^  10  ^t 


18  m  13 /u 

27  M  23  M 

32  M  19/11 


The  change  in  these  vessels  appears  to  be  identical  with  that 
increase  of  the  muscularis  which  has  now  been  long  recognised  in 
chronic  Brig'ht's  disease,  since  its  discovery  by  Dr.  Geo.  Johnston  ; 
no  notable  fatty  change  implicates  the  intima;  the  vessels  do  not 
here,  as  elsewhere  and  in  the  brain,  necessarily  show  atheromatous 
degeneration ;  nor  does  the  adventitial  sheath  betray  evidence  of  a 
reactive  inflammatory  condition.  The  immediate  environment  of  the 
vessel  shows,  in  most  cases,  a  normal  condition,  beyond  the  prevalence 
here  and  there  of  amyloid  bodies  in  juxtaposition  to  the  vessel.  Occa- 
sionally these  bodies  become  very  profusely  scattered  throughout  the 
whole  extent  of  the  white  columns  of  the  cord,  more  especially  around 
its  periphery  and  following  inwards  the  direction  taken  by  its  nutrient 
branches.  In  these  latter  cases  we  find,  however,  indications  of  an 
inflammatory  change — a  chronic  meningitis;  the  pia  being  often  greatly 
thickened,    its    vessels    much    distended,    and    its    meshes    containinsf 


Plate  XVII. 


S-pider  -cells  follo-ivinq  i^asciilar  trad 


Coarser-  vascular 
hraricKes  of 
S-pider-  cell. 


Spider    cells  with,   lona 
deliccLze    fibrils. 


Flexus  of  finer  fibrils. 


Scaven.ger     eleiaents     (Spider-  cells)   in   p eri^plieTal  zone 
ox-     1^     layer      of      tlie       Coxtex  —  IxxanaxL  "braixi.. 

X  240  . 


DISTRIBUTION    OF    SPINAL    LK.SIONS.  535 

leucocytes  and  inflammatory  products.  The  connective  trabeculse 
extending  from  the  pia  into  the  substance  of  the  cord  are  extremely 
coarse,  and  a  diffuse  sclerosis  thus  originating  often  affects  all  the 
medullated  tracts  of  the  spinal  cord.  Thus,  the  peripheral  zone  of  the 
cord  is  especially  implicated ;  and  the  sclerous  tissue  follows  more 
readily  the  course  of  the  larger  blood-vessels,  so  that  the  median  raphe 
of  the  posterior  columns  is  a  favourite  site  of  this  sclerous  change, 
which  often  extends  over  the  whole  of  the  columns  of  Goll.  The 
coarse  deep-channelling  by  blood-vessels,  and  the  profusion  of  scavenger- 
cells,  give  to  the  posterior  columns  a  notably  morbid  aspect.  In  a 
typical  case  examined  the  antero-lateral  columns  were  extensively 
implicated ;  the  pia  was  greatly  thickened ;  and  a  patchy  diffuse 
sclerosis  affected  the  anterior  root-zone,  and  the  lateral  columns,  together 
with  its  direct  cerebellar  tract.  The  various  segments  of  the  cord  also 
showed  much  irregularity  in  distribution  of  the  morbid  change,  and 
the  non-systematic  nature  of  the  lesion  was  clearly  demonstrated. 
The  posterior  nerve-roots,  also,  indicate  a  similar  interstitial  change  ; 
bundles  of  atrophied  nerve-tubuli  being  seen  imbedded  in  much  deep- 
stained  connective-tissue.  Atrophic  changes,  also,  had  involved  the 
cell-groupings  of  the  anterior  cornu ;  and  the  postero-lateral  group  in 
the  cervical  region  on  one  side  was  notably  affected,  few  cells  remain- 
ing, and  these  degenerated  as  the  result  of  the  invasive  sclerosic 
tissue.  The  intermedio-lateral  group  was  (in  the  lower  cervical)  in  a 
similar  state  of  degeneration  on  the  side  corresponding  to  marked 
sclerosis  of  the  lateral  column. 

The  intermedio-lateral  group  of  cells  appears  peculiarly  prone 
to  degeneration,  and  other  cell-groupings — e.g.,  the  antero-lateral  and 
the  internal  of  the  anterior  horn  on  the  same  side  are  thus  in  like 
manner  involved.  Clarke's  vesicular  COlumn  is  likewise  liable  to 
implication  in  these  affections.  Cornual  changes  are  by  no  means 
infrequent,  and  are  of  special  interest  here  in  relation  to  the  implica- 
tion of  special  cell-groupings  which  are  apt  to  present  themselves. 
Thus,  in  the  dorsal  region,  it  is  not  unusual  to  find  the  cells  of  the 
intermedio-lateral  column  of  one  side  plump  and  healthy ;  those  of  the 
opposite  side  being  utterly  degenerated  in  the  midst  of  a  dense  sclerous 
tissue  ;  the  same  unilateral  lesion  of  Clarke's  vesicular  column  may  also 
be  observed.  In  the  former  class  of  cases,  the  naked-eye  appearance 
presents  no  abnormality  in  sections  across  the  cord,  and  it  is  only  in 
the  second  series,  where  wide  tracts  of  connective  trabecule  traverse 
the  columns  of  medulla,  that  we  appreciate  morbid  change;  which  is  still 
more  apparent  when  the  stained  section  is  cleared  up  and  examined. 
That  the  posterior  nerve-roots  do  occasionally  participate  in  the  change 
has  already  been  stated ;  but,  that  the  spinal  changes  originate  in  the 


536  PATHOLOGICAL   ANATOMY    OP    ALCOHOLISM. 

affection  of  the  peripheral  nerves  is  by  no  means  probable ;  they  must 
be  regarded  as  coincident  affections.  Frequent  as  multiple  neuritis  is 
amongst  chronic  alcoholics  of  the  female  sex,  we  do  not  recall  any 
cases  occurring  in  alcoholic  insanity.  That  it  is  occasionally  met  with 
we  do  not  doubt,  although  the  jjercentage  of  insane  females  subject  to 
chronic  alcoholism  is  small ;  but  we  must  bs  prepared  to  regard  cases 
of  chronic  alcoholic  insanity  as  presenting  predispositions  which  more 
or  less  modify  the  tendency  to  peripheral  implication  of  the  nervous- 
system.  Whatever  ])e  the  explanation  of  this  paucity  of  cases  of 
multiple  alcoholic  neuritis  amongst  the  insane  community,  certain  it 
is,  that  alcohol  in  these  predisposed  subjects  does  tend  to  concentrate 
its  operations  chiefly  upon  the  vascular  membranes,  first,  of  the  brain 
and,  next,  of  the  spinal  cord. 

Patholog'y. — The  pathology  of  alcoholic  insanity  is  but  one  chapter, 
though  not  the  least  important,  in  a  long  history  of  retrogressive 
changes  to  which  the  whole  organism  is  subjected  through  the 
prolonged  operation  of  this  agent.  Through  the  medium  of  the  blood- 
vascular  system,  alcohol,  by  its  ready  absorption  and  permeability,  is 
rapidly  conveyed  to  the  most  distant  parts  of  the  organism,  establishing 
wide-spread  constitutional  disturbances;  whilst  through  the  peculiar 
selective  capacity  of  the  nervous  centres  for  this  poison,  it  thereupon 
expends  its  primary  and  most  potent  influence.  Although  in  all  cases 
the  nervous  centres  bear  the  chief  brunt  of  its  attack,  it  by  no  means 
follows  that  the  subjects  of  chronic  alcoholism  suffer  in  the  same  way. 
In  one,  the  gastric;  in  a  second,  the  hepatic;  in  a  third,  the  renal  and 
cardiac  symptoms  may  come  to  the  front;  whilst  in  others,  the  nervous 
centres  express  the  special  ^■irulence  of  the  agent  in  their  direction. 
Undoubtedly  a  neurotiC  heritag'S  plays  a  foremost  part  in  thus 
predisposing  to  more  exclusive  determination  of  the  morbid  agency 
upon  the  higher  nervous  centres,  just  as  those  subjects  predisjiosed  to 
renal  degeneration  will,  on  the  establishment  of  alcoholism,  display  the 
usual  cardio-vascular  changes  of  chronic  Bright's  disease.  Beyond  the 
limits  of  simple  functional  hyper-activity  of  the  nervous  centres  induced 
by  frequent  indulgence  in  alcoholic  drinks,  its  persistent  use  leads  to 
organic  change,  first  expressed  in  the  vessel's  wall  by  the  direct 
irritating  effect  of  the  spirit  on  its  tissue  elements.  A  chronic 
inflammatory  state  leading  to  extensive  atheromatous  and  fatty 
degeneration  of  the  intima  is  the  first  apparent  effect,  associated  with 
which  we  find  parallel  changes  undergone  by  the  adventitial  sheath  in 
the  increase  and  fatty  degeneration  of  its  elements.  Fat-emboli  are 
frequently  established  in  the  smaller  cortical  vessels  during  the  progress 
of  these  changes,  and  the  extensive  dilatation  and  aneurysmal  states 
described  above  are  probably  direct  results  of  the  diminished  resistance 


CIIHONIC    ENDARTERITIS — STEATOSIS    AND    SCLEROSIS.  537 

of  the  vessel,  and  paralysis  of  its  muscular  coat.  An  extensive 
endarteritis  of  a  most  chronic  and  insidious  chai-acter  affects  the 
ultimate  terminal  radicals  of  the  cortex,  and,  with  the  pre-existing 
change  in  the  composition  of  the  blood,  leads  to  the  devitalisation  of 
the  nervous  tissues,  undermining  the  nutritional  stability  of  the  nerve- 
cells.  The  subsequent  change  in  the  interstitial  tissue  around,  and 
the  nervous  elements  themselves,  apparently  depends  much  upon  the 
subject's  predisposition,  which  seems  to  be  the  chief  determining  factor 
in  engendering  the  fatty  or  sclerous  change  which  characterises  these 
two  classes  of  alcoholic  subjects.  In  all  alike,  however,  we  find  the 
tendency  to  a  degradation  of  tissue  in  the  replacement  of  the  normal 
elements  by  new  connective  growth;  but  in  some  we  find  a  special 
tendency  to  extensive  fatty  change  in  the  nervous  centres,  so  that  the 
parallel  degeneration  seen  elsewhere,  as  in  the  fatty  or  the  sclerosed 
liver,  seems  to  be  also  reproduced  here.  It  is  probable  that  the  fatty 
change  is  altogether  a  tnore  acute  process,  and  the  sclerosis  the  result 
of  a  much  slower  and  more  gradual  poisoning  of  the  tissues;  the  fatty 
Chang'e,  moreover,  is  much  more  liable  to  be  induced  in  the  case  of 
senile  alcoholics.  We  may  take  it,  that  the  changes  observed  in  the 
cerebral  meninges  as  well  as  in  the  soft  investment  of  the  cord,  when 
affected,  are  undoubtedly  indicative  of  a  very  chronic  inflammatory 
action  proceeding  in  the  vessels  of  the  membranes,  and  slowly  involv- 
ing the  upper  cortical  strata ;  for  thus  only  can  we  explain  the  frequent 
association  of  membi-anes  opaque  and  thickened,  and  the  permeation  of 
the  cortex  along  the  vascular  tracts  by  dense  connective  networks. 
Much  of  the  opacity  of  these  delicate  membranes  is  undoubtedly  the 
resulting  change  of  years  of  excessive  indulgence,  for  it  is  induced 
slowly  in  all  cases  of  long-continued  alcoholic  indulgence,  apart  from 
the  establishment  of  actual  insanity;  thus,  in  most  criminals,  who 
are  notoriously  addicted  to  drinking,  we  discover  such  opaque  and 
thickened  membranes,  and  this  usually  in  the  postero-parietal  regions 
of  the  brain  {Henry  Clarke). 

Coincident  with  this  implication  of  the  membranes,  a  similar 
change  is  found  throughout  the  nutrient  supply  of  the  medullated 
substance  of  the  convolution,  which,  as  before  stated,  leads  to  im- 
portant changes  in  the  lowermost  series  of  nerve-cells,  the  spindle- 
layer  and  the  medullated  nerve-fibres  themselves  at  this  site.  It  is 
obvious,  upon  examining  several  cases,  that  the  one  site  may  be 
chiefly  affected  to  the  greater  or  less  exclusion  of  the  other,  and  that, 
thus,  a  sclerous  change  in  the  peripheral  zone  of  the  cortex  may 
preponderate  over  any  morbid  change  at  a  greater  depth,  or  that  this 
deeper  implication  may  be  the  more  expressed  feature,  the  pia- 
arachnoid   being    free    from    notable    opacity  and    thickening.     It    is 


538  PATIIOLOOICAL    AN'ATOMY    OF    ALCOUOLISM. 

moi'e  usual,  however,  to  find  both  areas  ail'ected,  and  this  to  a  pro- 
found degree.  Certain  cases  of  chronic  alcoholism  approach,  as  we 
have  seen,  in  their  clinical  features,  the  history  of  general  paralysis ; 
and  when  we  come  to  the  morlnd  anatomy,  we  find  the  membranes  of 
the  brain  often  presenting  similar  appearances,  both  as  regards  naked- 
eye  aspects  and  distribution  of  lesion.  The  vascular  implication, 
however,  is  far  different,  and  cannot  be  readily  confused.  In  the  one 
(alcoholism)  the  morbid  change  is  centred  in  the  atheromatous  state 
of  the  inner  coat ;  the  numerous  bulgings  and  fusiform  dilatation 
being  also  highly  characteristic  of  this  chronic  inflammatory  implica- 
tion. The  outer  or  adventitial  investment  does  not  show  the 
enormous  nuclear  proliferation  which  is  so  notable  a  feature  in 
general  paralysis  (P/.  xvi.,  fig.  3);  although  in  degenerated  vessels 
it  will  be  the  seat  of  a  profusion  of  scavenger-cells  which  entangle 
its  walls  in  their  processes.  In  the  other  (general  paralysis),  as 
previously  stated,  the  morbid  change  is  concentrated  in  the  adven- 
titial sheath,  and  is  a  far  more  acute  irritative  process  in  the  loose 
external  tunic  of  the  vessel,  which  explains  the  more  rapid  implication 
of  the  nervovis  structures  lying  immediately  around  by  direct 
extension.  It  is  on  this  limitation  of  the  more  gross  change  for 
a  time  to  the  inner  tunic  of  the  hlood-vessels  in  chronic  alcoholism, 
that  the  slow  (yet  progressive)  impairment  of  nutrition  of  the  nerve- 
centres  depends,  which  so  frequently  issues  in  steady  enfeeblement 
of  the  mental  faculties,  akin  to  the  advancing  imbecility  of  senile 
atrophy,  in  which  similar  changes  of  the  vessel's  wall  occur.  It  is, 
on  the  other  hand,  in  the  early  implication  and  rapid  spread  of  morbid 
activity  along  the  adventitial  tunic  of  the  vessels  that  the  more  acute 
changes  are  induced  in  the  nerve-cells  of  the  cortex  in  the  general 
paralytic.  When,  however,  superadded  to  the  intravascular  lesions, 
we  find  sclerous  tissue  permeating  the  peripheral  zone  of  the  cortex, 
we  have  an  invasion  of  those  most  externally-disposed  medullated 
fibres  which  are  also  involved  in  general  paralysis  {PI.  y.\.,fig.  1).  It  is 
in  such  cases,  probably,  that  the  mental  symptoms  assimilate  to  those 
characteristic  of  general  paralysis.  The  sclerous  shrinking  of  the 
new  connective  formation  around  the  extensions  from  the  under- 
lying ganglionic  cells,  results  in  a  degeneration  which  is  ultimately 
transferred  to  these  cells  themselves,  inducing  the  already-described 
pigmentary  and  fatty  degeneration  preceding  their  absolute  destruction 
and  removal ;  but,  this  extensive  atrophy  of  these  large  elements  of 
the  cortex  is  coincident  only  with  the  most  advanced  fox'ms  of 
alcoholic  dementia ;  the  earlier  stage  of  vascular  impairment,  and 
the  growth  of  young  scavenger-cells  in  the  periphei-al  zone,  ere  the  cells 
are  themselves  involved,  being  apparently  associated  with  the  maniacal 


Plate  XVIII 


Swollen,  degeneraied 
ITerve-ccll. 


Vascular    p-rocess 
of  Svider-cell 


i 


S-pinoTzs  eoctensions  Jrorr^ 
va.scu.lccr  walls. 


-De gender diiTtp  ITeTve.- 
celLs   o-iia-cked.     hxr 

3n^.i'>-~-cell€. 


S-pvdLer-ce.ll    v/iiK  Us 
■va-scvcLar  px.ocess. 


Ariertcle.   surrozzn^ded    hu- 
Spi,djer  elemenis. 


-Defeneration    of    Nerve  -  cells     in    Corterc 
with   proliferation    of  the    Spider    or  Scavenger- cells. 
Section  from    ftfth    Cortical    layer    m   Motor  recicn. 

X    210. 


NATURE    OP   THE    SPINAL    IMPLICATION.  539 

excitement  and  early  delusional  perversions  of  alcoholism.  It  is 
certainly  a  remarkable  feature  that  in  both  afiections  we  get  a 
similar  implication  of  the  vascular  channels  of  the  pia  over  the 
almost  identical  motor  realms  of  the  cortex ;  that  in  both,  the  same 
nervous  elements  are  primarily  involved ;  and  that,  clinically,  there 
are  presented  to  us  so  many  features  in  common  between  the  two 
afiections,  that  it  often  becomes  a  moot  point  for  diagnosis.  This 
peripheral  implication  of  the  cortex  would  appear  to  us  to  explain 
the  grandiose  feeling,  so  frequently  commingled  with  the  delusions  of 
persecution,  from  which  alcoholic  subjects  suffer  ;  the  notions  of  wealth, 
of  landed  possessions,  of  exalted  social  status,  which  we  find  so  often 
underlying  delusions  of  restricted  liberty,  or  of  malign  influence 
brought  to  bear  upon  them.  When,  howevei',  the  motor  cell  and 
axis-cylinder  process  are  themselves  involved,  then  we  find  the 
characteristic  delusions  of  persecution  predominate  to  the  exclusion 
often  of  such  optimistic  states ;  and  the  profound  implication  of  the 
"  motor  element "  of  mind  may  call  forth  ideas  of  restricted  volitional 
freedom  and  reactive  capacity.  In  all  the  more  characteristic  phases 
of  chronic  alcoholism,  we  never  fail  to  identify  these  profound  lesions 
within  the  white  medullated  substance  of  the  fronto-parietal  lobe, 
associated  with  the  degeneration  and  breaking-up  of  the  large  "  motor- 
cells  "  and  spindle-series.  Whilst,  therefore,  the  cortical  lesions  of 
general  paralysis  indicate  an  invasion  from  without  inwards,  affecting 
the  sensory  elements  and  apical  (?  sensory)  poles  of  the  motor-cells  ; 
alcoholism  induces,  in  addition  thereto,  extensive  vascular  changes 
from  within  outwards,  implicating  the  medulla  of  tlie  gyri,  and 
effecting  a  destructive  degeneration  of  the  medullated  fibres. 

Spinal  Cord. — The  morbid  changes  found  in  the  spinal  axis  can 
scarcely  be  relegated,  in  any  typical  case  of  alcoholism,  to  one  of  the 
strict  system-affections  of  the  cord;  they  are  too  palpably  of  the  nature 
of  a  slowly-encroaching  sclerous  change  encircling  the  cord,  originating 
in  its  investing  membranes,  and  creeping  inwards  along  the  vascular 
tracts,  and  especially  along  the  posterior  median  raphe.  There  is  also, 
undoubtedly,  a  tendency  in  such  cases  to  a  frequent  implication  of  the 
posterior  nerve-roots,  by  a  similai-ly-disposed  lesion  spreading  into  its 
structure  from  its  perineural  investment,  inducing  a  change  quite  dis- 
similar in  nature  to  that  of  the  so-called  multiple  neuritis,  w'hich  also 
occurs  in  chronic  alcoholism.  The  investing  zone  of  sclerosis  is  by  no 
means  uniformly  advanced  at  all  points ;  more  frequently  we  observe 
a  decided  preponderance  at  certain  definite  arcs — e.g.,  the  marginal  arc 
of  the  lateral  column,  on  one  or  on  both  sides ;  or  the  segment  im- 
mediately adjacent  to  the  posterior  nerve- roots ;  or,  occasionally,  a 
section  of   the   outer    margin    of  the   anterior   root-zone;    and,   very 


540  PATHOLOGICAL    ANATOMY    OF    ALCOHOLISM. 

frequontly,  the  posterior  median  raph6,  spreading  thence  throughout 
the  columns  of  Golh  Whence  this  tendency  to  arise  at  different  sites? 
Wliat  are  the  determining  factors?  Although  we  cannot  reply  to 
these  questions  with  full  assurance  at  present,  yet  it  is  a  fact  of  no 
little  significance  that  such  lesions  are,  as  in  genei'al  paralysis,  dis- 
tributed along  the  columns  which  are  in  anatomical  connection  with 
discharging  tracts  at  higher  levels  in  the  cerebrum ;  and  that,  as  in 
general  paralysis,  we  find  system-degenerations  established  apparently 
along  columns  in  physiological  sympathy  with  diseased  tracts  higher 
up,  yet  not  hy  morbid  continuity ;  so  here,  also,  the  functional  dis- 
turbances aroused  in  the  cortex  may,  probably,  by  inducing  continuous 
engorgement  along  certain  spinal  ti-acts,  by  the  hyperactivity  of  their 
conducting  strands,  determine  to  that  region  the  chief  morbid  implica- 
tion. The  symptoms  accord  with  this  mode  of  implication,  for  we 
first  get  decided  evidence  of  a  very  chronic  lejyto-menijigitis,  which 
precedes  symptoms  of  ascending  and  descending  changes  secondarily 
induced  by  the  spread  of  the  lesion  inwards ;  and,  still  later,  we  find 
the  central  grey  matter  and  special  cell-groups  implicated,  apparently 
by  extension  along  the  nutrient  vessels,  by  the  same  lesion.  That  the 
symptoms  vary  greatly  in  individual  cases  is  not  surprising,  as  they 
wholly  depend  iipon  site,  and  depth  of  imj)lication  of  the  cord. 

The  lumbar  cord  may  be  the  first  affected,  and  the  deranged  sensory 
and  motor  symptoms  be  limited  wholly  to  the  legs ;  or,  again,  stiffness 
or  spasm  of  the  neck  and  retraction  of  the  head  may  indicate  cervical 
implication;  or  the  dorsal  region  may  be  the  site  of  most  pronounced 
implications ;  the  vertical  extent  of  the  meningeal  affection  may  be 
slight  or  universal. 

The  constitutional  state  engendered  in  chronic  alcoholic  insanity  is 
ideiitical  with  what  forms  the  basis  of  chronic  Bright's  disease ;  and  as 
in  this  affection  we  have  a  multiplicity  of  local  expressions  of  the 
morbid  lesions,  so,  here,  we  find  the  tendency  is  towards  a  concentra- 
tion in  the  nervous  centres  ;  atrophic  states  of  brain,  or  of  spinal  cord, 
or  of  both  combined,  are  thus  induced  from  predominance  of — 

{a.)  Simple  fatty  degeneration  of  their  nutritive  vessels  and  tissues. 

(6.)  From  fatty  degeneration  associated  with  interstitial  sclerosis. 

(c.)  From  diffuse  sclerous,  interstitial  change. 

(d.)  From  periai'teritis  and  hypertrophy  of  the  tunica  muscularis. 

In  the  periarteritis,  occasionally  engendered  in  chronic  alcoholics  of 
a  certain  age,  we  probably  see  the  pathological  boundary-line  over- 
stepped betwixt  simple  alcoholic  insanity  and  general  paralysis  of  the 
insane ;  and  we  have  resulting  therefrom,  in  a  more  acute  spread  of 
the  cortical  lesions,  what  might  be  regarded  as  general  paralysis 
accidentally   evolved    out    of  chronic   alcoholism,  or,  as    some  would 


NATURK    OF    THE    SPINAL    IMPLICATION.  541 

less  correctly  state  the  case,  general  jaaralysis  caused  by  alcohol. 
Alcohol  has  its  own  role  to  play,  and  a  most  extensive  one  it  is ;  but, 
the  tissue-changes  engendered  thereby  are  always  as  highly  character- 
istic as  are  the  morbid  sequences  of  general  paralysis,  and  we  must 
seek  to  dissever  from  the  latter  disease  our  notions  of  alcohol  playing 
the  part  of  a  direct  etiological  factor,  in  the  sense  of  originating  the 
primal  tissue-changes  by  which  this  disease  is  characterised. 

In  the  notable  thickening  of  the  muscular  tunic  of  the  arteries  seen 
in  the  spinal  cord,  in  certain  cases  of  alcoholic  insanity,  we  find  the 
general  symptomatology  points  to  the  depravation  of  the  nutrient 
fluids,  to  the  especially-vitiated  state  of  the  blood,  mal-assimilation, 
disordered  digestion,  deranged  excretory  functions,  bringing  in  their 
wake  the  resultant  changes  in  the  arterial  tunics.  In  such  cases,  as 
we  have  seen,  the  membranes  of  the  cord  presented  no  notable  change, 
and  no  coarse  sclerous  bands  of  connective  invaded  the  columns ;  the 
symptoms,  which  were  those  of  an  ataxic  paraplegia  of  very  gradual 
accession,  were  explained  by  the  great  predominance  of  scavenger-cells 
along  the  commissural  end  of  the  raphe,  with  morbid  vascularity  of 
the  posterior  columns  at  this  site,  the  vessels  all  presenting  great 
hypertrophy  of  their  muscular  tunic ;  a  remarkable  abundance  of 
amyloid  bodies  was  spread  throughout  the  peripheral  areas  of  the 
cord,  and  especially  the  posterior  columns.  The  lateral  columns 
exhibit  a  very  fine  punctated  connective,  which  has  induced  a  certain 
degree  of  atrophy  of  the  nerve-tubuli,  whilst  here  also  the  character- 
istic hypertrophied  muscular  vessels  prevail  abundantly  throughout 
all  regions  of  the  cord.  Nor  must  we  fail  to  call  attention  to  the  fact 
of  implication  of  the  visceral  column  of  the  cord — the  vesicular  formation 
of  Clarke.  A  very  general  implication  of  the  blood-vascular  system 
prevails ;  the  great  vessels  undergo  fatty  and  atheromatous  change ; 
and  the  circulatory  centre  itself — the  heart — being  an  early  sufi"erer, 
its  muscle  succumbs  to  fatty  infiltration  and  degeneration,  its  cavities 
dilate,  and  its  vital  capacity  is  profoundly  reduced.  Corresponding 
changes  appear  in  the  large  vessels  at  the  base  of  the  brain,  which 
become  atheromatous  and  distorted.  It  is  this  enfeeblement  of  centric 
circulatory  energy,  furthered  by  the  retarded  flow  of  blood  in  the 
minute  vessels,  which  calls  forth  that  compensatory  increase  of  the 
muscular  tunic  of  the  cerebral  and  spinal  arteries.  Another  factor, 
of  great  moment  here  for  evil,  must  not  be  overlooked,  that  is,  the 
diminished  vis  a  fronte  of  cortical  areas,  which  normally  favours 
circulation ;  a  failure  due  to  the  devitalisation  by  alcohol  of  the  nerve- 
tissue,  and  possibly  the  inherited  enfeeblement  of  neui-otic  descent. 


INDEX. 


Abdueens  facialis,  21,  23. 

nucleus  of,  19,  23. 
Acoustic  striffi,  10,  20,  21. 

,,        tubercle,  10. 
Activity,  restricted  central,  133. 
Adherent  pia,  histology  of,  442. 
Adhesions  of  pia,  441. 
Adolescence  and  alcoholic  excess,  289. 

,,  and  recurrent  insanity,  208. 

Adolescent  insanity,  334. 

,,  ,,    blood  in,  351. 

,,  ,,    etiology  of,  .359-361. 

,,  ,,    evolution  of,  .334. 

,,  ,,     prognosis  in,  362-364. 

,,  ,,    treatment  of,  364. 

Adventitial  coat  of  arteries,  76,  82. 

,,  ,,     of  capillaries,  77. 

Affective  insanity,  138. 
Ala  cinerea,  10. 

Alcohol,  efl'ects  of,  on  animals,  306. 
Alcoholic  insanity,  288-333. 

,,  ,,         a  convulsive  neurosis, 

291-.301. 
,,  ,,         acute,  297. 

,,  ,,         amblyopia  in,  298. 

,,  ,,         and  suicide,  292. 

chronic,  .303,  .308. 
,,  ,,         clinical  forms  of,  296. 

,,  ,,         delu.sions  in,  295,  296. 

,,  ,,         dyschromatopsia    in, 

298. 
„  ,,         evolution  of,  306. 

,,  ,.         fatty  degeneration  in, 

537. 
,,  „         hallucinations  in,  293. 

298,  316,  320. 
,,  ,.         muscular    spasm    in, 

328. 
,,  ,,         nature  of  attack,  291. 

,,  ,,         nystagmus  in,  .328. 

,,  ,,         pathological  anatomy 

of,  528-541. 
,,  ,,         jiredisposition,     291- 

293. 
^,  ,,         reaction-time  in,  326, 

327. 
,,  ,,         relapses  in,  299. 

,,  ,,         scavenger-cells  in, 

529. 


I  Alcoholism,  amnesic  fonns  of,  309,  311. 

,,  amj'loid  bodies  in,  529. 

,,  arachnoid  opacity  in,  436. 

,,  classification  of,  331-333. 

,,  climacteric  and,  402. 

,,  cortical  adhesions  in,  44"J. 

,,  tlelusional  forms  of,  312. 

chronic,  .303,  .308. 

, ,  en  V  ironmental  resist  ance  in , 

315. 

,,  epigastric  voice  in,  317. 

, ,  epileptiform  seizures  in.  .328. 

,,  general  paralysis  and,  538. 

,,  hypochondriasis  and,  147. 

,,  impulsive  insanity  and,  186. 

,,  motor  symptoms  in,  322. 

,,  nerve-ceUs  in,  529,  5.30-532. 

,,  object-consciousness  in,  .321. 

,,  peripheral  zone  in,  539. 

,,  senile  insanity  aud,  410. 

,,  sensorj'  troubles  in,  322. 

,,  sexual  illusions  in,  317. 

,,  spinal  cord  in,  532-536,  539. 

,,  symptoms  of  chronic,  .308. 

types  of,  333. 

,,  vascular  affections  in,  533- 

535,  540. 

,,  visceral  illusions  in,  317. 

Allhutt  {Dr.   Clifford)  on  the  optic  disc, 

171. 
Amnesia  in  alcoholism,  .309,  311. 
,,         in  senile  insanity,  414,  422. 
,,         (transient)  in  G.  I*.,  25.3. 
Amphibia,  brain  of,  55,  57. 
Amphioxus,      ,,         ~M. 
Amygdaloid  nucleus,  .35,  52. 
Amyotrophic  form  of  (J.  P.,  511-513. 
Anajmia,  signs  of  cerebral,  130. 
Anaesthetics,  action  of,  122. 
Andral  on  cerebral  hajmorrhage,  454. 
Angio-neuroses  in  G.  P.,  503. 
Angular  nerve-cells,  64. 
Ansa  peduncularis,  34,  .35. 
Ape,  cortex  of,  97. 
Apex-process  of  nerve-cells,  65,  67. 
Apoplectiform  seizures,  262. 
Aqueduct  and  central  grey  axis,  24,  .37. 
Arachnoid,  anatomical  relationships  of. 
4.34. 


INDEX. 


543 


Anichuoid   cysts,  4.37-441. 

,,  false  membranes,  437- 

,,  liaimorrliage,  origin  of,  441. 

,,  ,,  statistics      of, 

439-440. 
,,  opacities,  43G. 

Arcuate  fibres  of  medulla,  12. 
Arijy/l-Iiobartson  symptom  in  G.  P.,  265. 
Arndt  on  nerve-cells,  63. 
Arterial  areas  and  softening,  451,  452, 
491. 
,,         loops  of  cortex,  82. 
,,        supply  of  brain,  445. 
Arteries  in  G.  P. ,  494. 

,,        of  cerebral  cortex,  75. 
Arterio-capillary  plexuses,  82,  85. 
Articulatory  troubles  in  G.  P.,  258. 
Association  of  ideas,  failure  of,  164. 
Atavism  in  recurrent  insanity,  204. 
Atrophy,  cerebellar,  456-458. 
,,         cerebral,  454-458. 
,,  ,,  localised,  456-458. 

,,         chronic  cerebral,  407,  426. 
,,  ,,  and    Bright's 

disease,  429. 
,,  ,,  blood-vessels 

in,  430. 
,,  ,,  pulse  in,  429. 

,,  ,,  urea  in,  427- 

428. 
,,        senile,  417-455. 
Auditory  nerve-nuclei,  19. 
Aura,  auditory,  229. 
,,     epigastric,  181. 
,,     epileptic,  227. 
,,     gustatory,  230. 
,,     homicidal  impulse  and,  180. 
,,     oLfactory,  230. 
,,     organic  or  visceral,  230. 
,,     special  sense,  228. 
,,     vasomotor,  230. 
,,     visceral,  230. 
„     visual,  229. 
Automatic  segregation,  123, 
Automatism,   ejiileptic,    186,    234,  235, 
239,  244. 
,,  mania  and,  123. 

Axis,  central  grey,  1. 

,,      cerebro-spinal,  1. 
Axis-cylinder,  fibrillation  of,  72. 

,,  process,  65,  67,  71,  72. 

,,  staining  of,  74. 

Bain  (Prof.)  on  animal  appetites,  181. 
Basal  ganglia,  connections  of,  33. 

,,     process  of  nerve-cells,  65,  66. 
Beevor's  physiological  experiments,  109. 
Berrjmaiin,  sound-rod  of,  21. 
Betz,  giant  cells  of,  66,  95,  106. 
Birds,  brain  of,  57. 
Bladder  atrophy  in  G.  P.,  285. 
„        troubles  in  G.  P.,  284. 
Blood  in  acute  dementia,  161,  162. 


Blood  in  adolescent  insanity,  351. 
,,        general  paralysis,  288. 
,,        puerperal  insanity,  370. 
Blood-vessels     in     chronic     alcoholism, 
533-5.35. 
,,  of  cerebral  cortex,  75. 

Blumenbach  on  bony  falx,  436. 
Boll  on  spider-cells,  84. 
Bowel  troubles  in  G.  P.,  286. 
Brachia  of  quadingeminal  bodies,  37,  38. 
Brain  of  man  and  lower  mammals,  98. 
Bright's  disease  and  alcoholism,  540. 

,,  cerebral  atrophy, 

429,  534 
Broca's  cerebral  convolutions,  61. 

,,       extra-limbus,  87. 
Bromism,  151. 
Buchnill  [Dr. )  on  mania  and  melancholia, 

116. 
Bulbar  paralysis  and  colloid  change,  466, 

467. 
Bullen  (St.  John)  on  cortical  adhesions, 
442. 
,,  locomotor  ataxy  in 

G.  P.,  519. 
Burdach,  columns  of,  5. 

,,        lamina  meduUaris  of,  44. 

Calamus  scriptorius,  8. 
Calcarine  fissure,  60. 
Gcdmnl  on  pachymeningitis,  486 
Capillaries  of  brain,  76. 
Capsule,  internal,  28,  33. 

knee  of,  28. 
GarpeiUer  [Dr.)  on  alcohol,  305. 
Oarville  and  Buret,  113. 
Cat,  nerve-cells  of,  68,  97. 
Cataleptic  fixity  of  lind)s,  1 60. 
Caudate  nucleus,  28,  51. 
Central  grey  axis,  1. 
Centre  median  of  Luys,  45. 
Cerebellar  peduncle  (inner),  13. 

(outer),  10,  12,  13. 

,,         tract  (direct),  7 
Cerebral  seizures  in  G.  P.,  259. 
Cerebritis,  448. 
Cerebro-spinal  axis,  1. 

fluid,  437. 
Charcot  on  cerebral  hemorrhage,  454. 
Chronic  insane  class,  189. 
Circulation,  defective  cerebral,  129. 

,,  Heuhiier  and  Duret  on,  446. 

,,  mechanism  of  cerebral,  445. 

, ,  Moxon  ( Dr. )  on  cerebral,  445. 

Clarke  (Henry)  on  alcoholism,  537. 

,,      (Lockh(irt),  vesicular  columns  of, 
3,  IS,  ,535,  541. 
Claustral  formation  of  Mcynert,  70. 
Claustrum,  34,  54. 
Climacteric,  alcoholic  excess  at,  402. 

,,  convulsive  neuroses  at,  184» 

185. 

,,  recurrent  insanity  205,210, 


544 


INOKX. 


Climacteric  insanity,  392-405. 

,,  ,,         Clouslon  (Dr.)  oi\, 

401,  403. 
,,  ,,        delusions  in,  393. 

,,  ,,         etiology  of,  395. 

,,  ,,         jMemou  (Dr.)  on, 

403. 
,,  ,.         prognosis  in,  401. 

,,  ,,         sexual     illusions 

in,  404. 
,,  ,,         statistics  of,  398. 

,,  ,,         transformations 

of,  398,  399. 
,,  ,,         treatment  of,  404. 

Clustered  cells  of  cortex,  96. 
Colloid  degeneration,  4(55-470. 

,,  bulbar      paralysis 

and,  466,  467. 
,,  histology  of,  408- 

470. 
„  Kes/.eve7i  on,  469. 

M'Kendrick  (Dr.) 

on,  465. 
Tuke  (Dr.  Batty) 
on,  465. 
Commissure,  anterior,  30. 

,,  posterior,  37,  48. 

Compensation,  functional,  113. 
Conarium  aud  brachia,  37. 
Congenital  defect  and  relapses,  205. 
Conjugate  deviation  in  G.  P.,  262. 
Connective  cells  of  brain,  79, 80,  497, 505. 

,,  matrix  of  brain,  78. 

Consciousness,  faint  aud  vivid  states,  1 1 S. 
,,  lapsed  states,  120. 

,,  object-  and  subject-,  116. 

Consecutive  dementia,  190. 
Consensual  movements  in  G.  P. ,  275. 
Convulsions,  senile,  408. 
Convulsive   neuroses   and  alcohol,   291, 

,301,  329. 
Corii'il  and  Banvier  on  nerve-fibres,  73. 
Cornu  Ammonis,  type  of,  89. 
Cornu,  anterior,  4. 

,,      caput  and  cervix,  .3. 
,,       posterior,  3,  513. 
Corpora  albicantia,  30,  44. 
,,        genicidata,  28,  48. 
,,        quadrigemina,  28. 
,,        striata,  28. 
Corpus  trapezoides,  15,  23. 
Corpuscles  of  nerve-fibres,  73. 
Correspondence,  variations  in  the,  116. 
Cortex  cerebri,  62. 
,,      depth  of,  95. 
,,      excitability  of,  111,  112. 
,,      functional  equivalence  of,  113. 
,,      histology  of,  63. 
,,      lamination  of,  85. 
Cortical  adhesions,  441,  442. 

,,  and  alcoholism,  442. 

Coupland  (Dr.)  on  meningeal  engorge- 
ment, 446. 


Craniun),  morbid  states  of,  433. 
Crichlon- Browne  (Sir  J.)  on  arachnoid 
hifimorrhage,  4.39. 
,,  biain  weights,  489. 

<i.  P.,  254. 
,,  localisation,  490. 

Critical  periods  of  life,  128. 
Crucial  sulcus,  97. 
Crusta,  27. 

,,       passage  into  capsule,  31. 
,,       system  of  fibres  in,  31. 

Danilo  on  phosphorus  poisoning,  480. 
Deafness,  depression  accompanj'ing,  132. 
Decorative  tendency  in  G.  P.,  257. 
Decussation,  anterior  sensory,  24. 

,,  of  cerebellar  peduncle,  37. 

,,  of  trochlear  nerve,  26. 

Degeneration,  colloid,  465. 
fatty,  471. 

fuscous,  473,  496,  .500. 
,,  granular,  471,  530,  534. 

,,  miliaiy,  458. 

,,  pigmentary,  473, 496,  500, 

524. 
Degradation  (tissue)  from  disease,  486. 
,,  from  disuse,  487. 

,,  from  overstrain, 

4S5. 
DeUer.'i'  cells,  S3. 

,,       protoplasmic  processes  of,  71. 
Delirious  mania,  172,  176. 
Delirium,  alcoholic,  297. 
Delusional  forms  of  alcoholism,  312. 

,,  insanity,  192. 

Delusions,  genesis  of,  126. 

, ,  in  alcoholic  insanity,  295,  296, 

,,  ,,  climacteric  insanity,  393. 

,,  ,,  epileptic  insanity,  245. 

,,  ,,  general  paralysis,  255. 

,,  of  senile  and  monomaniacal, 

421. 
,,  optimistic,  295. 

,,  transient,  164. 

Dementia,  acute  primary,  157,  162, 
,,  consecutive,  190. 

,,  secondary  and  tissue   degra- 

dation, 482,  489. 
,,  senile,  4US. 

Dentate  nucleus,  13. 
Denudations,  uniform  and  partial,  176. 
Depression,   conditions  of  pathological, 
116. 
,,  definition  of,  115. 

,,  degrees  of,  137. 

,,  reaction-time  in,  .327. 

,,  .states  of,  115,  150. 

Deprivation,  mental,  188. 
Developmental  arrest,  177,  188,476,479. 
Diffusion-currents  in  epilepsy,  222. 
Discharge  (nerve)  in  alcoholic  insanity, 
320. 
„  ,,      epilepsy,  526. 


INDEX. 


545 


Dissolution  in  senile  insanity,  414. 
,,  planes  of,  128. 

Disuse  (functional)  and  tissue-degrada- 
tion, 487. 

Divergencies  in  laminar  type,  94. 

Bonders  on  pupillary  reactions,  276. 

Dudfey  {Dr.  Wm. )  on  cerebellar  atrophy, 
457. 

Dura  mater,  adhesions  of,  435. 
,,         ,,       bony  plates  in,  4.36. 
J  J         ,,       inflammation  of,  435,  436. 
,,         ,,       morbid  states  of,  434-436. 

Durand-Fardel  on  htemorrhage,  454. 

Buret,  researches  of,  113,  114,  435,  446. 

Dynamic  attributes  of  perception,  119. 

Dyschromatopsia  in  alcoholism,  298. 

EbePth  on  the  capillaries,  78. 

,,  ,,       vascular  tunics,  76. 

Echer  on  the  convolutions,  60. 
Effort,  sense  of  conscious,  121. 
Egoism  of  the  general  paralytic,  251. 
,,         ,,       pubescent  subject,  338. 
Elastic  coat  of  cortical  arteries,  75. 
Electric  stimulation  of  cortex,  113. 
Eminentiae  teretes,  9,  10. 
Encephalon,   comparative  and  embryo- 
logical,  55. 
Enfeeblement,  states  of  mental,  188. 
Enuresis  in  G.  P.,  286 
Environment   in  monomania,  193. 

,,  physical  and  physiological, 

143. 
,,  resistance  of,  119,  121,  124, 

315. 
,,  transformations  of,  126. 

Epicerebral  space,  76,  81. 
Epigastric  voice  in  alcoholism,  317. 
Epilepsia  larvata,  185,  186. 
Epilepsy,  aura  in,  227. 

,,        automatism  of,  186,  234,  235, 

239,  244. 
,,        dreamy  state  of,  185,  186. 
,,         (grand  et  petit  mal),  231. 
,,        nuqldings- Jackson     (Br.)    on, 

525. 
,,        impulsive  states  of,  242,  244. 
, ,        interparoxysmal  stage  of,  239. 
,,        natui'e  of,  525. 
,,        nucleus  of  nerve-cells  in,  523- 

525. 
,,        pathology  of,  522-528. 
,,        piginentarv    degeneration    in, 

524. 
, ,        post-paroxysmal  period,  232. 
,,        premonitory  stage  of,  227. 
,,        pre-paroxysmal  jjeriod  of,  226. 
,,        senile,  408. 
,,        sensory,  225. 
,,        vacuolation  of  nuclei,  523-525. 
Epileptic  discharge,  221. 

,,        hypochondi'iasis,  241. 
,,        katatonia,  238. 


Epileptic  mania,  233. 
,,        neurosis,  221. 
,,        paroxysm,  230. 
„        status,  2.38. 
Epileptic  insanity,  221-250. 
,,         definition,  221. 
,,         degrees   of  reduction  in, 

223. 
,,         delusional  states  in,  245. 
,,         diffusion-currents  in,  222. 
,,         discliarge    from    sensory 

areas,  224. 
,,         homicide  in,  247. 
,,         hysterical  attacks  of,  235. 
,,         malingering  in,  246. 
,,         medico-legal  aspects,  243. 
,,         nascent  nerve-tracks,  223. 
,,         reaction-time  in,  242. 
,,         treatment  of,  249. 
Epileptiform  attacks  in  alcoholism,  328. 
„       G.  P.,  260,  261. 
Equivalence,  functional,  113. 
Esquirol  on  the  mimetic  tendency,  187. 
Ewald  on  the  keratoid  sheath,  73. 
Exaltation,  definition  of,  162. 

,,  impulsive  states  in,  166. 

,,  states  of  mental,  162-176. 

Excitability  of  cortex.  111,  112. 
Explosiveness  of  nerve-tissue,  131. 
Extra-limbic  type  of  cortex,  89. 
Extra-polar  conduction,  114. 

Facial  nerve,  genu,  20,  22. 

nucleus,  19,  20. 
Falx  cerebri,  Bhimenbach  on,  436. 

,,  ossification  of,  436. 

Fasciculus,    posterior   longitudinal,    24, 
34,  40. 
,,  retroflexus,  47. 

,,  solitarius,  8,  11,  17. 

„  teres,  9. 

Feelings,  tlie  non-relational,  116. 
Ferrier{Br.  Dd.)  on  the  convolutions, 61. 
„  ,,       frontal    lobes, 

493. 
,,  ,,       motor  area,  96. 

,,  physiological      experi- 

ments, 109,  111. 
Fifth  nerve,  ascending  root  of,  11,  22. 
Fillet,  15,  23,  37. 
, ,      of  crus,  34. 
Fimbrite,  44. 
Fishes,  brain  of,  55,  56. 
Fissure,  calcarine,  60. 

,,        hippocampal,  60. 
Flechsig,  ground-fibres  of,  5. 
Flesch  on  phosphorus  poisoning,  480. 
Flexures,  cranial,  59. 
Fore-brain,  configuration  of,  49. 
Formatio  reticularis,  4,  14. 
Fornix,  pillars  of,  30,  44. 
Franck  and  Fiires,  researches  of,  112. 
Friction,  Romanes  on  ganglionic,  133. 
35 


546 


INDEX. 


Fritsch  and  Hitzig,  researches  of,  111. 
Fromann^s  striatious,  72,  73. 
Frontal  lobe,  functions  of,  491,  49.3. 
Fulminating  psychoses,  131,  17G,  181. 
Funiculus  gracilis  and  cuneatus,  9,  11. 
Fuscous  degeneration,  473,  476. 

Galezowski  on  chromatic  anaesthesia, 

298. 
Gallon,  reaction  register  of,  135. 
Ganglia  of  crust  and  tegment,  27. 

,,        olfactory,  56. 
Ganglion,  basal  optic,  49. 
Ganglionic  cells  of  cortex,  95. 

,,         layer  of  motor  area,  101. 
Gaskell's  visceral  system  of  nerves,  4. 
Gelatinous  substance  of  Rolando,  3,  11, 

513. 
General  Paralysis,  250-288. 

,,         amyotrophic  form  of,  511- 

51.3. 
,,         angio-neuroses  in,  503. 
,,         ataxic  form  of,  518-520. 
,,         articulation  in,  258. 
, ,         atrophy  of  bladder  in,  285. 
,,         bladder  troubles  in,  284. 

blood  in,  288. 
,,         bowel  troubles  in,  286. 
,,         cerebral  seizures  in,  259. 
,,         chronic     alcoholism     and, 

538. 
,,         classification  of,  502. 
,,         deep  reflexes  in,  278,  281. 
,,         delusions  of,  255. 
,,         early    moral    perversions, 

252. 
, ,         early  paresis  in,  254. 
, ,         enfeebled  attention  in,  253. 
,,         epileptiform    seizui'es    in, 

259,  261. 
,,         facial  expression  in,  258. 
,,         first  stage  of,  497. 
,,         genuine  tabetic  form,  520. 
,,         headache  in,  521. 
,,         membranes  in,  497. 
, ,         meningeal      hfemorrhage, 

499. 
,,         nerve-elements  of  cord,507. 
,,         oculo  -  motor      symptoms, 

263-277. 
,,        paralytic  seizures  in,  262, 

263. 
, ,         parenchymatous   myelitis, 

509. 
,,         pathological    anatomy   of, 

493-521. 
,,         prodromal  stage  of,  251. 
,,         pseudo  -  tabetic    form    of, 

513-518. 
,,         reaction-time  in,  263. 
,,         rheumatoid  pains  in,  520. 
,,        scavenger-cells  in,  494-497, 
505. 


General  Paralysis,  second  stage  of,  500. 
, ,         self  -  decorative    tendency 

in,  257. 
, ,         sexual  perversions  in,  257. 
,,         spinal  cord  in,  501-521. 
,,  ,,      symptoms   in,    277, 

501. 
,,         syncopal  attacks  in,  259. 
,,         tabetic  gait  in,  281. 
,,         thii'd  stage  of,  501. 
,,         transient  amnesia  in,  253. 
,,        vascular    implication    in, 

504. 
,,        vasomotor     derangement, 
254. 
Geniculate  bodies,  28,  38. 
Gestation,  insanity  during,  374-376. 
Giant  cells  of  Bctz,  66,  106. 

,,  cortex,  95. 

Globose  cells,  69. 
Globus  pallidus,  54,  55. 
Glosso-pharyngeal  origin,  17. 
Golgi  on  sender- cells,  84. 
Gall's  columns,  5,  506. 
Gowers,  ascending  sensory  tract  of,  5. 
,,       on  epileptic  automatism,  186. 
Granular  disintegration,  471-473. 
Granule  cell,  64,  94. 
Gratioltt  on  the  convolutions,  61. 
,,       olfactory  area  of,  53,  91. 
,,       optic  radiations  of,  33,  44. 
Griesinger  on  araclinoid  opacities,  435. 
,,  cerebral  irritation,  117. 

,,  chronic  dementia,  191. 

Groupings,  significance  of  cell-,  106. 

Haemoglobin  in  G.  P.  diminished,  288. 

,,  puerperal  insanity,  370. 

Hffimorrhage,   Andral  and  Charcot  on, 

454. 

„  arachnoid,  437-441,  499. 

,,  Crichton- Browne  (6'ir)  on, 

439. 
,,  Laivson  {Dr.  Robert)  on, 

440. 
,,  Rokitanshj  on,  438. 

Hallucination  in  alcoholic  insanity,  293, 
298,  316,  320. 
,,  in  lactational  period,  382. 

,,  iu  recurrentinsanity,215. 

,,  in  seclusion,  167. 

Hemiplegic  seizures  in  G.  P. ,  263. 
Heredity  and  senility,  408. 

,,         iu  recurrent  insanity,  203,  204. 
Heubner  on  cerebral  circulation,  446. 
Hippocampal  fissure,  60. 
His,  perivascular  canals  of,  76,  81. 
Hitzig,  localisations  of,  61. 

,,      physiological  experiments  of,  109, 
111. 
Homicidal  impulse,  179. 
,,  insanitj-,  184. 

Homicide  and  epilepsy,  247. 


INDEX. 


547 


Horn  (anterior),  motor  cells  of,  4. 

,,     (posterior),  sensory  cells  of,  3,  513, 
Horned  cells  of  cortex,  G8. 
Horskij  {Victor),  localisations  of,  61. 

,,  on   the    frontal    lobes, 

492. 
,,  physiological       experi- 

ments of,  109,  112. 
Hughlhigs-Jachson  (Dr.)   on  the  nerve- 
cells,  &c.,  109,  222,  223,  525. 
Hunger  of  the  nerve-cell,  131. 
Huss  (Magnus)  on  chronic  alcoholism, 
304. 
„  on  classification  of  alco- 

holism, 331. 
,,  on       Swedish      dram- 

drinkers,  307. 
Huxley  on  the  convolutions,  61. 
Hypnotism  and  stupor,  152-154. 
Hypoaria,  56. 
Hypochondriacal  melancholia,  143. 

,,  ,,       at     puberty, 

146. 
,,  ,,       delusions  of, 

144-147. 
,,  ,,       morbid  crav- 

ings of, 147. 
„  ,,       suicide      in, 

147. 
,,  cesophagismus,  144. 

Hypochondriasis,  epileptic,  241. 

,,  senile,  417. 

Hypoglossal  nuclei,  16. 
Hypophysis  cerebri,  58. 
Hysteroid  attacks  in  epilepsy,  235. 

Identity,  failure  of,  124. 
Idiocy,  nerve- cells  in,  70. 
Illegitimacy  and  puerperal  insanity,  369. 
Illiisions  (sexual)  in  alcoholic  insanity, 

317. 
Imaginative  faculties  in  mania,  169. 
Imitativeness  of  youth,  337. 
Impulse  and  alcoholic  excess,  186. 

„  ,,         insanity,  291, 301. 

,,      and  dreamy  state  of  epilepsy, 

185. 
,,      homicidal,  179. 
,,  ,,  aura  in,  180. 

, ,  , ,  masked  epilepsy,  1 85. 

,',      insane,  178,  179. 
Impulsive  features  in  epileptic  insanity, 
242,  244. 
,,  ,,  mania,  166. 

,,  ,,         recurrent  insanity, 

214. 
,,        insanity,  131. 
Incidence  of  insanity  as  to  age,  397. 
Incoherence  of  mania,  169. 
Incontinence  in  G.  P.,  284. 
Inflammation  of  brain,  448. 
Inflated  cells,  69. 
Infundibulum,  50. 


Inhibition,  110,  111,  526. 

Insects,  cephalic  ganglion  of,  56. 

Insula,  .30,  54,  60. 

Intemperance  and  recurrent    insanity, 

204,  216. 
Interannular  segments,  73. 
Intercalated  layers,  105. 
Intermedio-lateral  tract,  4,  535. 
Intima  of  capillaries,  77. 

,,         cortical  arteries,  75. 
Intracellular  digestion,  494. 
Iridoplegia,  associative,  265. 
,,  reflex,  265. 

Kahlbaum  on  katatonia,  238. 
Katatonia,  epileptic,  238. 
Keratoid  sheath,  73. 
Kesteven  on  colloid  degeneration,  469. 

,,  miliarj^  sclerosis,  458. 

Knee-jerk  in  G.  P.  (aljolished),  280. 

,,  ,,  (increased),  278. 

Kolliker  oh  nerve-])rocesses,  72. 
Kreyssig  on  phosphorus  poisoning,  480. 
Kries  and  Auerhach  on  reaction-time,  136. 
Kuhne  on  the  keratoid  sheath,  73. 
Kupffer's  stratum  moleculare,  92. 

,,  ,,         reticulare,  92. 

Labile  equilibrium,  201. 
Lactation,  insanity  during,  376. 
„  physiology  of,  386. 

,,  risks  of,  376. 

Lactational  insanity,  delusions  of,  377. 
„  ,,  etiology  of,  384. 

,,  ,,  hallucinations,  382. 

,,  ,,  prognosis,  389. 

, ,  , ,  sexual  perversions, 

382. 
,,  ,,  suicide,  379. 

,,  ,,  symptoms,  377. 

,,  ,,  treatment,  391. 

Lacunar  laj'er  of  cornu  Ammonis,  92. 
Lamina  meduUaris  of  Burdach,  45. 
Laminae  medullares,  54. 
Laminar  arrangement  of  cells,  96. 
,,        types  of  cortex,  88,  105. 
Lamination  of  cornu  Ammonis,  89,  92. 
,,  cortex,  85. 

,,  extra-limbus,  89,  91. 

limbic  (upper),  88,  89. 
,,  ,,      (modified    upper), 

88,  90. 
,,  motor  area,  99-101. 

olfactory  bulb,  89,  93. 
,,       type  (inner),  88, 
91. 
,,  ),  ,)   (modified), 

89,91,105. 
„  ,,  „  (outer),    88, 

90. 
Lamprey,  55. 

Landois  on  nerve-processes,  72. 
Landois  and  Stirling  on  growth,  336. 


548 


INDEX. 


Lantermann  on  nerve-til)rcs,  73. 
Latent  period,  Ladd  (Prof.)  on,  130. 

,,  ,,       of  stimulation,  111,  136. 

Lateral  mixed-system,  12,  17. 

„  ,,         sensory     nucleus 

of,  17. 
Lawson  (Dr.  Robert)  on  arachnoid  cysts, 

438. 
Lemniscus,  23,  37,  38. 
Lenticular  nucleus,  28,  49,  54. 
Lewes   (G.   //.),    antagonism  of  growth 

and  development,  336. 
Limbic  arc  of  rabbit's  brain,  86. 
„        ,,    type  of  upper,  88,  89. 
,,      lobe,  6-1. 

,,      type,  modified  upper,  88,  90. 
Localisation  of  function,  61. 
Locomotor  ataxia  in  G.  P.,  518. 
Locus  cceruleus,  25. 

,,     niger,  30. 
Luys''  centre  median,  45,  63. 
Lymph-connective  system,  83,  484. 

,,  ,,    in  senile  atrophy, 

44.3,  484,  488. 
Lymphatic  system  of  brain,  80. 
Lyra,  44. 

Magnan  on  alcoholism,  304,  308,  309, 

333. 
Major  (Dr.  H.  C.)  on  cerebellar  atrophy, 
457. 
J,  granular  degenera- 

tion, 457,  471. 
Malingering  in  epilepsy,  246. 
Mania,  acute  delirious,  172,  176. 
,,      bodily  symptoms  in,  171. 
,,       epileptic,  233. 
,,      onset  of,  168. 
,,      periodicity  of,  172. 
,,      a  potu,  297. 
,,      senile,  406. 
,,      symptoms  of,  170-171. 
,,      tempei-ature  in,  172-173. 
,,      transitoria,  187. 
Marc  on  homicidal  impulse,  181. 
Marcet  (Dr.)  on  alcoholic  diseases,  307. 
Mas'mrj  (Evxlolf)  on  alcohol,  305. 
Masturbation  and  insanity,  355,  358,360. 
Maudsley  (Dr.)  on  mania  transitoria,  187. 
Medico-legal  aspects  of  epilepsy,  187. 
Medulla  oblongata,  8. 

,,  columns  of,  12,  20. 

Medullary  groove,  57. 
,,  laminae,  34. 

MeduUated  interannular  segments,  73. 

,,  nerve-fibre,  72. 

Melancholia,  affective,  137,  138, 
J,  agitans,  147. 

,,  clinical  groups  of,  138,  142. 

delusional,  138,  141. 
,,  hypochondriacal,  143. 

senile,  407,  418. 
,,  stu]iorose,  155. 


Melancholic  stadium,  108. 
Menstrual  derangement  imd  convulsive 
neuroses,  184. 
,,  and    recurrent     in- 

sanity, 207. 
,,  and     stupor,     341, 

346,  349. 
Mercier  (Dr.    Chas.)     on    the    nervous 

system,  525. 
Mer.tun  (Dr.)  on   climacteric    insanity, 

398,  403. 
Mesencephalon,  27. 

Metsckn'ikoff  on  intracellular  digestion, 
494. 
,,  phagocytes,  494. 

Meynert  on  cerebellar  atrophy,  456. 
,,  cortical  lamination,  88. 

,,  depth  of  cortex,  95. 

,,  nerve-cells,  63,  67,  68,  70. 

Mimetic  tendency,  Esquirol  on,  187. 
Molecular  stratum  of  Kupffer,  92. 
Monomania,  cases  of,  194,  200. 
,,  delinition  of,  192. 

,,  environmental      resistance 

in,  193. 
,,  genesis  of,  192. 

,,  mystic  symbolism  in,  194. 

,,  perverted  ideation  in,  193. 

Monoplegic  seizures  in  G.  P.,  263. 
Monro,  foramen  of,  58. 
Moral  perversion  in  G.  P. ,  253. 
Mosso  on  cerebral  circulation,  446. 
Motor  area  of  cortex,  99. 

,,     cell-groupings,  102,  104. 
,,     cells,  66,  101. 

,,     enfeeblenient  in  alcoholism,  323. 
Moxon  (Dr.   W.)  on  the  cerebral  veins, 

445. 
Muscular  coat  of  arteries,  75,  53.3. 

,,         element  of  mind,  118,  121. 
Mydriasis,  paralytic,  264. 
Myelitis,  parenchymatous,  509. 
Myosis,  paralytic,  264. 
,,       spastic,  264. 

Nates,  structure  of,  38. 
Negative  states  of  mind,  1 1 7. 
Nerve-cells,  63-70. 

,,  angular,  64. 

,.  comparative  size  of,  108. 

,,  developmental  arrest,  475- 

479. 

,,  granule,  64. 

, ,  Iluqhlings-Jachion  (Dr. )  on, 

i09. 

,,  inflated  or  globose,  69. 

,,  motor,  66. 

,,  nucleus  of,  109-111. 

,,  primitive    and    degenerate 

type,  478,  527. 

,,  pyramidal,  65. 

,,  Boss  (Dr.)  on,  527. 

,,  significance  of  form,  527. 


INDEX. 


549 


Nerve-cells,  significance  of  size,  107. 

,,  spindle-shaped,  70. 

Nerve-discharges  in  alcoholism,  320. 
Nerve-fibres,  71-75. 

,,  corjniscles  of,  73. 

,,  destruction  of,  482. 

„  naked,  71. 

Nerve-tracts,  forcing  of  nascent,  223. 
Nested  cells  of  cortex,  96,  102. 
Neural  canal,  57. 
Neuro-enteric  canal,  58. 
Neuroglia  cells,  79,  80. 

,,         matrix,  78. 
Niemeyer  on  puncta  vasculosa,  448. 
Nocturnal  crises,  166. 
Notochord,  59. 

Nuclear  lamina  of  Ammon's  horn,  92. 
Nucleus,  acoustic  (anterior),  21. 

,,  ,,         (external),  21. 

,,  ,,         (internal),  20. 

„        ambiguus,  25. 

,,        amygdaloid,  52. 

,,        caudatus,  28,  51. 
clavate,  7,  8,  12,  14. 
cuneate,  7,  8,  12,  14. 

,,        dentate  (cerebellum),  13. 
facial,  20,  23. 

,,        hypoglossal,   10,  12,  16. 

„        of  lateral  columns,  14,  17,  20. 

,,        lenticularis,  30,  49,  54. 

,,       of  nerve-cells,  109,  111. 

,,        of  oculo-motor,  26. 

,,        ruber   of  tegmentum,   26,  37, 
39. 

,,        sacral  (Stilling),  4. 

„       tecti,  13,  23. 

,,        trigeminal  (motor),  25. 

,,        troclilearis,  26. 

,,        vacuolation  of,  523. 

,,        vago- accessory,  10,  12. 
Nursing  mother,  qualifications  of,  389. 
Nutritive  impairment,  acute,  129,  130. 
Nystagmus  in  alcoholism,  328. 

ObersteineP  on  the  lymphatics,  80. 
Object-consciousness,  failure  of,  116, 118, 

137,  321. 
Oculo-motor  nucleus,  26. 

symptoms  in  G.  P.,  263-277. 
ffisophagismus  in  hypochondriasis,  144. 
Ogston  {Dr. )  on  alcohol,  305. 
Olfactory  area,  53,  91. 

bulb  (type),  89. 
,,        cortex  (type),  88,  89. 
Olivary  body  (accessory),  15. 
,,  ,,      (inferior),  14,  20. 

,,  ,,      (superior),  19,  23. 

,,       fasciculus,  15. 
Optic  disc  in  mania  (Dr.  Allbutt),  171. 
,,     ganglion  (basal),  49. 
,,     nerve  (origin),  49. 
,     radiations  of  Gratiolet,  33,  44. 
Optimism  m  alcoholic  insanity,  295. 


Orfila  on  alcoholic  poisoning,  305. 
Ovarian    derangement    at    pubescence, 

346,  .349. 
Over-strain  and  tissue-degradation,  485. 

Paehymening-itiS  (externa),  435,  4,36. 

,,  (interna),  437. 

Pain  and  pleasure,  genesis  of,  133,  134. 

,,    in  G.  P.,  520,  .521. 
Paretic  states  in  alcoliolism,  325. 
Parietal  sulcus,  primary,  87. 
Pathology  of  chronic  alcoholism,   528- 
541. 
,,  epileptic  insanity,  522-528. 

,,  general  paralysis,  493-521. 

,,  insanity,  489-492. 

,,  secondary    dementia,    482- 

488. 
Peduncles  of  pineal  gland,  42,  47. 
,,         of  thalamus,  35,  51. 
,,         superior  cerebellar,  37,  39. 
Peduncular  sensory  tract,  32,  33,  34. 
Perception,  statical  and  dynamic  attri- 
butes of,  119. 
Percy  [Dr.)  on  alcoholic  stimuli,  305. 
Pericellular  sacs,  81. 
Periodicity  of  maniacal  reductions,  172, 
Perivascular  cells,  82. 

,,  channels,  76,  81. 

Personality,  double,  125. 

,,         transformations  of,  124,  127. 
Perversions,  monomaniacal,  193. 
Pia-arachnoid,  adhesions  of,  441. 

,,  alcoholic  excess,  436. 

,,  morbid  states  of,  436. 

,,  opacities  and  thickening 

of,  436. 
Pig,  nerve-cells  of,  68,  70,  96. 
Pigmentary  degeneration,  473-476. 
Pineal  body,  37,  47. 
Pitres,  researches  of,  112. 
Pituitary  body,  30,  58. 
Pneumogastric  in  hypochondriacal  mel- 
ancholia, 144. 
Pons  Varolii,  19. 

,,  brachia  of,  19. 

Popow  on  phosphorus  poisoning,  480. 
Positive  states  of  mind,  117. 
Posterior  perforated  space,  30. 
Pregnancy,  insanity  during,  374-376. 
Premature  senility,  426. 
Primary  processes  of  cells,  67,  71. 
Prunitive  nerve-fibrils,  71- 
Prognosis  in  pubescent  insanity,  362-364. 
,,  puerperal       ,,        371, 

recurrent        ,,        214-220. 
Protoplasmic  processes,  66,  71. 
Pseudo-tabetic  G.  P.,  513-518. 
Psycho-motor    centres,     contiguity    of, 

114. 
Puberty,  egoism  of,  338. 

,,        initiative  tendency  in,  338. 
,,        Smith  (Dr.  Edward)  on,  337. 


550 


INDEX. 


Pubescent  epoch  and  convulsiveneuroses, 
184. 
,,  ,,      and  insanity,  212,  334. 

,,  ,,      cvolutidn  of,  334. 

, ,  } ,      ill  ^he  female,  335. 

„     in  the  male,  3r)2-.354. 
,,  insanity,  ancestral  influence 

in,  344,-  345. 
,,  ,,  and  ansemia,  .342. 

„  etiology  of,  343, 359-.361. 
,,  ,,  iu  the  female,  339. 

,,  ,,  in  the  male,  354. 

,,  ,,  masturbation    in,    355, 

358,  360. 
,,  ,,  ovarian  derangement  in, 

346-349. 
,,  ,,  prognosis  in,  362-364. 

,,  ,,  stupor  in,  341. 

,,  ,,  treatment  of,  364. 

Puerperal  insanity,  blood  in,  370. 

,,  ,,    etiology  of,  367-370. 

,,  ,,    illegitimacy  and,  369. 

, ,  , ,    intensity  of  excitement, 

365. 
,,  ,,    prognosis,  371. 

,,  ,,    sexual  element,  365. 

,,  ,,    suicide  in,  367. 

,,  ,,    treatment  of,  373. 

,,         period  and  insanity,  365. 
Pulvinar,  42. 

Pupils  in  general  paralysis,  263-277. 
Pyramidal  tracts  (crossed),  6. 
J,  (direct),  5. 

,,  (in  crusta),  32. 

Quadrig-eminal  bodies,  28,  36. 

Quetelet  on  growth,  336. 

Rabbit,  nerve-cells  of,  68. 

, ,         topography  of  brain  of,  86. 
Pvadiations  of  Gratiokt,  33. 
Ranvier,  nodes  of,  73. 
Peat,  nerve-cells  of,  68. 
Reaction-time  in  alcoholic  insanity,  135, 
326,  327. 
,,  epileptic  insanity,  242. 

,,  exaltation  and  depression, 

327. 
,,  generalparalysis,  135, 263. 

,,  healtli  aud  disease,  135. 

,,  Krits   and   Auerhacli  on, 

1.36. 
,,  melancholia,  134, 1.35,  .327. 

Reconstructive    period    of    climacteric, 

400. 
Recoverability  of  mania  and  melancholia, 

190. 
Recurrent  insanity,  201-220. 

,,  adolescent  subjects 

and,  208. 
„  age  and,  210. 

,,  alcoholic  excess  and, 

204,  216. 


Recurrent  insanity,  atavism  and,  204. 

,,  climacteric  subjects 

and,  205,  210. 
,,  congenital       defect 

and,  206. 
,,  definition  of,  201. 

, ,  farinaceous   dietary 

and,  220. 
,,  hallucinations      in, 

215. 
,,  heredity  and,  203. 

,,  incidence  of  attack, 

202. 
,,  menstrual  irregular- 

ities and,  207. 
, ,  morbid  impulse  and, 

214. 
,,  nature     of     attack, 

205,  206. 
, ,  neurotic  heritage  in, 

2U3,  204. 
,,  prognosis    in,    217- 

220. 
, ,  puerperal    subjects 

and,  211. 
Sankey{Dr.)on,20l. 
,,  senile    epoch    and, 

211. 
,,  stuporose  states  in, 

2U7. 
,,  traumatism       and, 

213. 
,,  treatment  of,  220. 

Reductions,  epileptic,  223,  240. 
,,  melancholic,  138. 

,,  senile,  414,  419. 

Reflexes  (deep)  in  G.  P.,  278. 
Regional  distribution  of  nerve-cells,  95. 
lieid  on  climacteric  insanity,  398. 
Reil,  island  of,  30. 

,,     substantia  innominata  of,  34. 
Pie-iutegration,  127. 
Relation,  definition  of,  120. 
Relational  element  of  mind,  decline  of, 

120. 
Representativeness,  enfeebled,  118. 
,,  vigour  of,  123. 

Reptiles,  brain  of,  57. 
Resistance,  sense  of,  119,  120. 
Restiform  columns,  10,  12. 
Pvestriction  of  the  will,  120,  315. 
Retention  in  G.  P.,  284. 
Reticular  formation,  4,  14. 
Reticulated  stratum  of  Kupffer,  92. 

,,  white  substance,  86. 

Revivability  of  impressions,  310. 
Rhythm,  nutritional,  1.32. 
Rodents,  brain  of,  63,  86. 
Bokilansl')/  on  arachnoid  opacities,  436. 
, ,  on  engorged  membranes,  446. 

Rolando,  fissure  of,  60. 

„         tubercle  of,  25. 
Romanes  on  "ganglionic  friction,"  133. 


INBEX. 


551 


Roof-nuclei  of  Stilling,  13,  23. 
Root-zones  of  cord,  8. 
Boss  {Br.)  on  the  lateral  cell-groups,  14. 
,,  ,,  ,,     mixed  system,  4. 

nerve-cells,  482,  527. 

Sankey   (Dp.)  on   recurrent  insanity, 
201. 

Scavenger-cells  and  chronic  alcoholism, 
529-533. 
fibrillation  of,  83,  497. 
,,  general    paralysis   and, 

494-505. 
,,  miliary     sclerosis    and, 

462. . 
,,  nerve-fibre  plexus  and, 

483-488. 
,,  senile  atrophy  and,  443. 

,,  spinal  cord  and,  505. 

(S'cAa/er's  researches,  112,  492. 
Sclerosis,  miliary,  458. 

histology  of ,  460-464. 
,,  scavenger-cells  in,  462. 

Seclusion  and  hallucination,  167. 
Secondary  processes  of  cells,  67,  71. 
Senile  amnesia,  414,  422. 
,,       atrophy,  417. 
,,       convulsions,  408. 
,,       dementia,  408. 
,,       epilepsy,  408. 
,,       hypochondriasis,  417. 
,,       mania,  406. 
,,       melancholia,  407. 
Senile  epoch,  changes  of,  405. 

,,         recurrent  insanity  and,  211, 
Senile  insanity,  adhesions  in,  444. 
„  amnesia  of,  414,  422. 

,,  alcohol  and,  410. 

,,  atrophy  and,  417. 

,,  delusions  and,  421. 

,,  onset  and  prodromata,  413. 

,,  reductions  of,  414,  419. 

,,  scavenger-cells  in,  443. 

,,  sexual  perversions  in,  416. 

Senility,  premature,  410,  426,  456. 
Sensory  areas  in  epileptic  insanity,  224. 
,,        cells  of  posterior  horn,  4. 
,,        columns,  termination  of,  32. 
,,        nerves  of  skin,  144. 
,,        troubles  in  alcoholism,  321. 
Seriality  of  thought,  disturbed,  118. 
Sexual  divergence,  336,  352. 
,,       element  in   puerperal   insanity, 

365. 
,,        illusions  in  alcohohsm,  317. 
,,       perversions  of  G.  P.,  257. 
,,  5,  of  lactational  cases, 

382. 
Sheath  of  Sclnoann,  73. 
Sheep,  nerve-cells  of,  68,  96. 
Skae  {Dr. )  on  climacteric  insanity,  398. 
Smith  (Dr.  Edward)  on  puberty,  337. 
Softening,  cerebral,  450. 


Softening,  localised,  452,  453,'491. 
Solitary  arrangement  of  cells,";^94,  96. 

,,        fasciculus,  8,  17. 
Sound-rod  oi  Bn-ymann,  21. 
Spasmodic  states  in  alcoholism,  328. 
Spencer   (Herbert),    automatic    segrega- 
tion, 123. 
,,        faint  and  vivid  states,  118. 
,,        relational    and     non  -  rela- 
tional feelings,  116. 
,,       variations    in    the     corre- 
spondence, 116. 
Spider-cells,  83. 

in  G.  P.,  494. 

,,  in  senile  atrophy,  443. 

Spiegelherg  on  growth  and  development, 

336. 
Spinal-accessory,  origin  of,  17. 
Spinal  cord,   alcoholism  (chronic)  and, 
539. 
,,  amyotrophic   implication, 

511-513. 
,,  anterior  radicular  zone,  8. 

,,  antero-lateral  columns,  7. 

,,  bilateral  symmetry  of,  2. 

,,  cell-groupings  of,  4. 

,,  combined     system-disease 

of,  510. 
, ,  commissural  tracts  of,  8. 

, ,  direct  cerebellar  tract  of,  7. 

inG.  P.,  501-521. 
,,  intermedio-lateral  tract  of, 

4. 
,,  medullated  columns  of,  5. 

,,  posterior    columns  of,  24, 

513,  524. 
,,  pyramidal  tracts  of,  5,  6, 

506. 
Spinal  symptoms  in  G.  P.,  277. 
Spindle-cells  of  cortex,  70. 
Statical  attributes  of  perception,  119. 
Status  epilepticus,  238. 
Stcqjliany  on  nerve-cells,  63. 
Stigmata,  77. 

Stimulation  (electric)  of  cortex,  113. 
Stomata,  77. 

Stratum  gelatinosum,  93. 
,,      glomerulosum,  93. 
,,      granulosum,  93. 
,,      reticulare,  92. 
,,      zonale,  .15,  35,  46,  51. 
Striaj  acoustica?,  10,  20,  21. 

,,     terminales,  53. 
Striate  layer  of  cornu  Ammonis,  92. 
Stui)or,  blood  in,  350. 
,,        causes  of,  151. 
,,        hj'pnotism  and,  152-154. 
,,        recurrent  insanity  and,  207. 
,,        melancholia  with,  155-157. 
„       states  of,  150-162. 
Style  of  pineal  peduncle,  47. 
Subject-consciousness,  rise  of,  116. 
Subjective  in  lower  organisms,  143. 


652 


INDEX. 


Substantia  ferniginea,  25. 

,,  gelatinosa,  3,  513. 

,,  iiuioininata,  34. 

„  nigra  {Soemmering),  36,  40. 

Subthalamic  body,  42. 
Suicidal  impulse,  187. 
Suicidal  promptings,  140,  147. 
Suicide  in  alcoholic  insanity,  292. 

,,  hypochondriasis,  147. 

,,  puerperal  insanity,  367. 

Sulci,  significance  of,  97. 
Surcingle,  52. 

Suspicion,  genesis  of,  124,  140. 
Sweden,  excessive  alcoholism  in,  307. 
Syhnan  aqueduct,  37. 

,,       fissure,  60. 
Symbolism,  mystic,  194. 
Syncopal  attaciis  in  G.  P.,  259. 
System-diseases  of  the  cord,  506. 

Tabetic  gait  in  G.  p.,  281. 
Taenia  pontis,  30. 

,,     semicircularis,  53. 
Tegmentum,  27,  37. 
Temperature  in  mania,  172,  173. 
Thalamencephalon,  41. 
Thalamic  capsule,  46. 

„         connections  with  hemispheres, 

46. 
„        fasciculi  (direct  and  decussat- 

ing),  45._ 
,,         peduncle  (inferior),  35. 
,,         tubercle,  43. 
Thalamus  opticus,  28,  42. 
Thought,  muscular  element  of,  119. 
Tilt  on  climacteric  insanity,  398. 
Toxtemia,  129. 

Transitional  forms  of  cortex,  88, 104, 105. 
Traumatism  and  recurrent  insanity,  213. 
Treatment  of  epilepsy,  249. 
Trifacial,  ascending  root  of,  11,  22,  25. 
Trigeminal,  descending  root  of,  25. 
,,  median  root  of,  25. 

,,  motor  nucleus  of,  25. 

Trigonum  olfactorium,  53. 
Trochlear  nerve,  nucleus  of,  26. 

,,  root-fibres  of,  26. 

Trousseau  on  growth,  336. 


Tubercle  of  thalamus  (anterior),  42,  46. 
Tuke  (Dr.   Batly)  on  colloid  degenera- 
tion, 465. 
,,  miliary   sclerosis, 

458,  464. 
Tithe  (Dr.  Hack)  on  homicidal  impulse, 

180,  183. 
Tunica  adventitia,  76,  78. 
,,      media,  75,  78. 
,,      muscularis,  75,  78. 
Tiirck,  columns  of,  5. 
Turner  (Prof.)  on  the  convolutions,  61. 
Types  of  cortical  lamination,  88. 
,,      divergence  in,  94. 
,,      five-  and  six-laminated,  97. 
Typho-mania,  173. 

Uterine  involution  and  insanity,  376. 

VaeUOlation  of  nerve-cell,  479-480. 

of  nucleus,  480-482,  523- 
525. 
,,  in  phosphorus  poisoning, 

480. 
Vagus,  origin  of,  17,  18. 
Vascular  implication  in  alcoholism,  533. 
,,        process  of  scavenger- cells,  83. 
Vascularity  of  cortex  in  insanity,   444, 

447. 
Veins  of  cortex,  77. 
Velum,  anterior  medullary,  24. 
Venous  engorgement  of  membranes,  446. 
Ventricle,  iloor  of  fourth,  24. 
Vesicles,  cerebi-al,  57. 

,,        optic,  58. 
Vesicular  columns  of  Clarke,  3,  18. 
Vicq  cVAzyr's  bundles,  44. 
Virchoiu  on  pachymeningitis,  437. 
Visceral  columns  of  Lockhart  Clarke,  3, 
18,  535,  541. 
,,        illusions  in  alcoholism,  293,  317. 
,,        nerve-nuclei  of  Gaskell,  4. 
Volition,  i-estriction  of,  120,  122. 

Waldeyer  on  nerve-processes,  78. 
Wi7i.-ilow  (Dr.  Forbes)  on  suicide,  188. 

Youth,  mimetic  tendency  of,  307. 


THE    END. 


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Milk.  .  ,  -  -  1,00 
Leffmann's  New  Compend.  i.oo 
Muter.  Pract.  and  Anal.  2.00 
Richter's  Inorganic.    3d  Ed.   2.00 

Organic.        -        •  3.00 

Stammer.     Problems.     -  .75 

Sutton.  Volumetric  Anal.  5.00 
Symonds.     ManuaJ  of.  2.00 

Tidy.  Modern  Chem.  2d  Ed.  5.50 
Trimble.    Analytical.      -  1.50 

Valentin.  Qualt.  Anal.  7th  Ed.  3.00 
Watts,     (towne's)  Inorg.         2.25 

(Fowne's)  Organ.  2.25 

Wolff.     Applied  Medical.  i.oo 

CHILDREN. 
Chavasse.    Mental  Culture  of.  i.oo 
Day.     Dise.Tses  of.  -        -  3.00 

Dillnberger.  Women  and.  j-50 
Ellis.     Mother's  book  on.  .75 

Goodhart  and  Starr.  3  00;  Sh,  3.50 
Hale.     Care  of         -        -  .75 

Hillier.     Diseases  of.       -  1.25 

Meigs.      Infant   Feeding    and 

Milk  Analysis.         -        -  i.oo 

Meigs  and  Pepper's  Treatise. 5. 00 
Money.     Treatment  of.    -  3  00 

Osier.  Cerebral  Palsies  of.  2.00 
Smith.     Wasting  Diseases  of.  3.00 

Clinical  btudies.  -  2.50 

Starr.  Digestive  Organs  of.  2.50 
Hygieneof  the  Nurserj'.  i.oo 


COM  FENDS 
And  The  Quiz-Contpendi. 
Brubaker's  Physiol.  4th  Ed.  $1.00 
Kox  and  Gould.  The  Eye.  i.oo 
Horwitz.  Surgery.  3d  Ed.  i.oo 
Hughes.  Practice.  2  Pts.  Ea.  i.oo 
Landis.  Obstetrics.  4th  Ed.  i.oo 
Leffmann's  Chemistry.  2d  Ed.  i.oo 
Mason.     Electricity.        -  i.oo 

Morris.     Gynaecology.     -  i.oo 

Potter's   Anatomy,   4th  Ed.     i.oo 
Materia  Medica.  5th  Ed.  i.oc 


Roberts.  Mat.  Med.  and  Phar.  2.00 
Stewart,  Pharmacy.  2d  Ed.     i.oo 

DEFORMITIES. 
Churchill.  Face  and  Foot.  3.50 
Coles.  Of  Mouth.  -  4.50 
Prince.  Orthopaedics.  -  4.50 
Reeves.  "  -  2.25 
Roberts.  Club-foot.  -  .50 
Noses.                        -  .50 

DENTISTRY. 
Barrett.     Dental  Surg.   -  i.oo 

Blodgett.  Dental  Pathology.  1.75 
Fillebrown.  Op.  Dent.  lUus.  2.50 
Gorgas.  Dental  Medicine.  3.50 
Harris.     Principles  and  Prac.  7.00 

Dictionary  of.       -  6.50 

Heath.     Dis.  of  Jaws.    -  4.50 

Lectures  on  Jaws.  Bds.  i.oo 

Leber    and    Rottenstein. 

Caries.      Paper  75 ;  Cloth  1.25 

Richardson.    Mech.  Dent.  4.50 

Stocken.     Materia  Medica.  2.50 

Taft.    Operative  Dentistry.  4.25 

,  Index  of  Dental  Lit.  2.00 

Talbot.  Irregularity  of  Teeth.  2.00 

Tomes.     Dental  Surgery.  5.00 

Dental  Anatomy.  4.00 

■White.    Mouth  and  Teeth.  .50 


DICTIONARIES. 
Clevelaod's  Pocket  Medical.     .75 
Gould's  New  Medl.    ^^  Lea., 

3.25:  i^  M.  Thumb  Index.  4.25 
Harris'  Dental.  Clo. 6.50;  Shp.  7.50 
Longley's  Pronouncing  -  i.oo 

Treves.     German  English.       3.75 

DIRECTORY. 
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EAR. 
Burnett.     Hearing,  etc. 
Jones.    Aural  Surgery.     - 
Pritchard.     diseases  of. 

ELECTRICITY, 

Althaus'  Text  Book. 
Masoo's  Compend. 
EVE. 
Arlt.     Diseases  of.   -        - 
Fox  and  Gould.    Compend.  i.oo 

Gower's  Oplnhalmoscopy.       

Harlan.     Eyesight.  -  .50 

Hartridge.  Refraction.  3d  Ed.  2.00 
Higgins.     Practical  ManuaJ.    1.75 

Handbook,  -  .50 

Liebreich.  Atlas  of  Ophth.  15.00 
Macnamara.  Diseases  of.  4.00 
Meyer  and  Fergus.  Com- 
plete I'exl-B  jok,  with  Colored 
Plates.  270  lllus.  Clo.  4.50:  Sh.5.50 
Morton.  Refraction.  3d  Ed.  1.00 
Ophthalmic  Review. 

Monthly.  -  3.00 


•  SO 
2-75 
1.50 

6.00 
I.oo 


2.50 


FEVERS. 
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Welch.     Enteric  Fever.  2.00 

HEADACHES. 
Day.     Their  Treatment,  etc.     1.25 
Wright.     Causes  and  Cure.        .50 

HEALTH  AND  DOMESTIC 
MEDICINE. 
Bulkley.    The  Skin.        -  .50 

Burnett.     Hearing.  -  .50 

Cohen.  Throat  and  Voice.  .50 
Dulles.  Emergencies.  3d  Ed.  .75 
Harlan.     Eyesight.  -  .50 

Hartshorne.  Our  Homes.  .50 
Hufeland.     Long  Life.   -  i.oo 

Lincoln.     Hygiene.         -  .50 

Osgood.  Dangers  of  Winter.  .50 
Packard.    Sea  Air,  etc.  .50 

Richardson's  Long  Life.  .50 

Tanner.     On  Poisons.     -  .75 

White.  Mouth  and  Teeth.  .50 
Wilson.  Summer  and  its  Dis.  .50 
Wilson's  Domestic  Hygiene,  i.oo 
Wood.     Brain  Work.      -  .50 

HEART. 
Fothergill.     Diseases  of.  3.50 

Sansom.     Diseases  of.     -  1.25 

HISTOLOGY. 
See  Microscope  and  Pathology. 

HYGIENE. 
Bible  Hygiene.       -        -  i.oo 

Frankland.  Water  Analysis,  i.oo 
Fox.     Water,  Air,  Food.  4.00 

Lincoln.  School  Hygiene.  .50 
Parke's  fE.)  Hygiene.  7th  Ed.  4.50 

(L.  C.),  Manual.  2.50 

Starr.  Hys<ieneof  the  Nursery,  i.oo 
Wilson's  Handbook  of.  -  2.75 

Domestic.     -        -  i.co 

JOURNALS,  Etc. 
Archives  of  Surgery.  4  Nos.  3.00 

Jl.  of  Laryngology.    12     "  3.00 

1.  of  Dermatology.    "     "  3.00 

Ophthalmic  Review.  "  "  3.00 
New  Sydenham  Society's 

Publications     -        -        -  9.00 

KIDNEY  DISEASES. 
Beale.     Renal  and  Urin.  1.75 

Edwards.     How  to  Live  with 

Bright's  Disease.    -        -  .50 

Greenhow.  Addison's  Dis.  3.00 
Ralfe.  Dis.  of  Kidney,  etc.  2.75 
Tyson.     Bright's    Disease 

and  Diabetes,  lUus.  -        3.50 

LIVER. 
HabershoD.     Diseases  of.         1.50 
Harley.     Diseases  of.      -  3.00 

LUNGS  AND  CHEST. 

See  Phy.  Diagnosis  and  Throat. 

Hare.     Mediastinal  Disci-se.    2.00 

Harris.     On  the  Chest.   -  2.50 

Williams.     Consumption.        5.00 

MATERIA  MEDICA. 
Biddle.     nth  Ed.    Clo.  4.25; 

Sheep,  -  -  -  -  5.00 
Gorgas.  Dental.  3d  Ed.  3.50 
Merrell's  Digest.  -  4.00 
Potter's  Compend  of  5ih  Ed.  i.oo 
Handbook    of      Second 

Ed.  Clo.  4.00 ;  Sheep,  -  5.00 
Roberts'  Compend  of.  2.C0 


CLASSIFIED  LIST  OF  P.  BLAKISTON,  SON  &-  CO:S  PUBLICATIONS. 


MEDICAL  JURISPRUDENCE. 
Reese.   Medical  Jurisprudence 
,    &Toxicology,2d  Kd  3.00;  bh;j3.5o 
Woodman  and  Tidy's  Treat- 
ise, including  Toxicology.        7.50 

MICROSCOPE. 
Bcale.     How  to  Work  with.     7.50 

In  Medicine.         -  7.50 

Carpenter.     The  Microscope. 

Lee     Vade  Mecum  of  

MacDonald.     Examination  of 

Water  by.        -        -        -  2.75 

Wythe.    The  Microscopist.  3.00 

MISCELLANEOUS. 

Burdett.     Hospitals.         -  a. 25 

Beale.     Life  Theories,  etc.  2.00 

Slight  Ailments.  1.25 

Bioplasm.      -        -  2.25 

Life  and  Vital  Action.  2.00 

Black.     Micro-organisms.  1.50 

Crookshank.  Vaccination.  8.50 
Davis.  1  ext-book  of  Biology.  4.00 
Duckworth.     On  Gout.  -  7.00 

Edwards.     Vaccination.  .50 

Gross.  Life  of  John  Hunter.  1.25 
Haddon.  Embryology.  -  6.00 
Henry.    Anaemia.  -        -  .75 

Holden.  The  Sphygmograph.  2.00 
MacMunn.  The  Spectroscope  3.00 
Madden.  Health  Resorts.  2.50 
Smythe.     Med'l  Heresies.        1.25 

MASSAGE. 

Murrell.  Massage.  4th  Ed.  1.50 
Ostrom.     Massage.     lUus.  .75 

NERVOUS  DISEASES,  Etc. 

Flower.   Atlas  of  Nerves.  3.50 

Bowlby.  Injuries  of.  -  4.50 
Gowers.    Manual  of.     i  vol. 

341  Illustrations.         -        -  6.50 

Dis.  of  Spinal  Cord.  

Diseases  of  Brain.  2.00 

Syphilis  and  the  Ner- 
vous System.  -         -  

Obersteiner.   Central  Nervous 

System.    -         -         -         -         

Osier.     Cerebral  Palsies.  2.00 

Page.     Injuries  of  Spine.  

Radcliffe.  Epilepsy,  Pain,  etc.  1.25 
Thorburn.      Surgery    of    the 
bpinal  Cord    -        -        -  4.50 

NURSING. 
CulUngworth.    Manual  of.      1.00 

Monthly   Nursing.  .50 

Domville's  Manual.  6th  Ed.  .75 
FuUerton,  Obst.  Nursing.  1.25 
Humphrey.     Manual  of  1.25 

Luckes.  Hospital  Sisters.  i.oo 

Parvin.  Obstetric  Nursing.  .75 
Starr.  Hygiene  ot  the  Nursery,  i.oo 
Temperature  Charts.    -  .50 

OBSTETRICS. 
Bar.     Antiseptic  Obstet.  1.75 

Barnes.  Obstetric  Operations.  3.75 
Cazeaux  and  Tarnier.     Stu- 
dents'   Ed.     Colored  Plates.  5.00 
Galabin's  Manual  of.       -  3.00 

Glisan's  I'ext-book.  2d  Ed.  4.00 
Landis.  Compend.  4ih  Ed.  i.oo 
Meadows.     Manual.       -  2.00 

Rigby.     Obstetric  Mem.  .50 

Schultze.  Diagrams.  -  25.00 
Strahan.  Extra-Uterine  Preg.  1.50 
Tyler  Smith's  1  realise.  4.00 

Swayne's  Aphorisms  gth  Ed.  1.25 
Winckel's  Text-book.  6.00 

PATHOLOGY  &  HISTOLOGY. 

Blodgett.  Dental  Pathology  1.75 

BowlDy.     Surgical  Path.  2.00 

Gibbes.    Practical.           -  1.75 

Gilliam.     Essentials  of.  -  2.00 

Rindfleisch.     General.  2.00 

Sutton.     General  Path.  -  4.50 

Virchow.     Post-mortems.  i.oo 

Cellular   I'athoiogy.  4.00 


PHARMACY. 
Beasley's  Druggists'  Rec'ts.  $2.25 

l-ormulary.     -        -  2.25 

Fliickiger.  Cinchona  Barks.  1.50 
Kirby.  Pharm.  of  Remedies.  2.25 
Mackenzie.  Phar.  of  Throat.  1.25 
Merrell's  Digest.     -        -  4x0 

Proctor.  Practical  Pharm.  4.50 
Stewart's  Compend.  2d  Ed.  i.oo 
Tuson.     Veterinary  Pharm.     2.50 

PHYSIOLOGY. 
Beale's  Bioplasm.    -        -  2.25 

Brubaker's  Compend.     Illus- 
trated.    4th  Ed.      -        -  1.00 
Kirkes'  12th   Ed.     (Author's 

Ed.)  Cloth,  4.00;  Sheep,  5.00 
Landois'  Text-book.  583  Illus- 
trations. 2d  Ed.  -  -  6.50 
Sanderson's  Laboratory  B'k.  5.00 
Sterling.  Practical  Phys.  2.25 
Tyson's  Cell  Doctrine.    -  2.00 

Yeo's  Manual.  321  Illustrations 
3d  Ed.    Cloth,  3,00;  Sheep,  3.50 
POISONS. 
Aitken.    The  Ptomaines,  etc.    1.25 
Black.     Formation  of.      -  i  50 

Reese,  Toxicology.  2d  Ed.  3.00 
Tanner.     Memoranda  of.  .75 

PRACTICE. 
Beale.     Slight  Ailments.  1.25 

Fagge's  Practice.  2  Vols.  8.00 
Fenwick's  Outlines  of.    -  1.25 

Hughes.  Compend  of.   2  Pts.  2.00 

Physicians'  Edition. 

I  Vol.  Morocco,  Gdt  edge.  2.50 
Roberts.  Text-book.  7th  Ed.  5.50 
Tanner's  Index  of  Diseases.  3.00 
Taylor's  Manual  of.     -  4.50 

Warner's  Case  Taking.  1.75 

PRESCRIPTION  BOOKS. 
Beasley's  3000  Prescriptions.   2.25 

Receipt  Book.        -  2.25 

Formulary.     -        -  2.25 

Pereira's  Pocket-book.  i.oo 

Wythe's  Dose  and  Symptom 

Book.     17th  Ed.     -        -  I.oo 

RECTUM  AND  ANUS. 

Allingham.    Diseases  of.  1.25 

SKIN  AND  HAIR. 
Anderson's  Text-Book.  4.50 

Bulkley.    The  Skin.        -  .50 

Crocker.    Dis.  of  Skin.    lUus.  5.50 
Van   Harlingen.      Diagnosis 
and  Treatment  of  Skin  Dis. 
Col.  Plates  &  Engravings.       2.50 
STIMULANTS  &  NARCOTICS. 
Lizars.     On  Tobacco.     -  .50 

Miller.     On  Alcohol        -  .50 

Parrish.     Inebriety.        -  1.25 

SURGERY  AND  SURGICAL 

DISEASES. 
Caird  and  Cathcart.    Surgi- 
cal Handbook.  Leather,  2.50 
Dulles.     Emergencies.        -        .75 
Heath's  Operative.  -        12.00 

Minor,    gth  Ed.      -  2.00 

Diseases  of  Jaws.  4.50 

Lectures  on  Jaws.  1.00 

Horwitz.   Compend.    3d  Ed.    i.oo 
Jacobson.     Operations  of.    -     5.00 
Porter's    Surgeon's    Pocket- 
book.  -        -     Leather.  2.25 

Roberts.    (A.  S.)  Club-Foot.    .50 

(A.  S.)    Bow-Legs.  .50 

Smith.  Abdominal  Surg.  7.00 
Swain.  Surg.  Emergencies.  1.50 
Walsham.  Practical  Surg.  3  00 
Watson's  Amputations.  5.50 

TECHNOLOGICAL  BOOKS. 
See  also  Chemistry. 
Cameron.     Oils  &  Varnishes.  2.50 

Soap  and  Candles.  2.25 

Gardner.     Brewing,  etc.  1.75 

Gardner.    Acetic  Acid,  etc.     1.75 

Bleaching  &  Dyeing.     1.75 

Groves  and  Thorp.  Chemi- 
cal Technology.  Vol.  I. 
Mills  on  Fuels.  CI.  7.50;  YzW.  g.co 


Overman.     Mineralogy.         $1 
Piggott.     On  Copper.      -  i 

THERAPEUTICS. 
Biddle.  nth  Ed.  CI.  425  ;  Sh. 
Cohen.     Inhalations. 
Field.  Cathartics  and  Emetics. 
Headland.    Action  of  Med. 
Kirby.     Selected  Remedies. 
Mays.     Therap.  Forces. 
^——  Theine         ... 
Ott.     Action  of  Medicines. 
Potter's  Compend.     5th  Ed. 

,  Handbook  of.  4.00  ;  Sh. 

Starr,  Walker  and  Powell, 

Phys.  Action  ot  Medicines. 
AVaring's  Practical.    4th  Ed. 

THROAT  AND  NOSE. 
Cohen.     Throat  and  Voice. 

Inhalations. 

Greenhow.     Bronchitis. 
James.     Sore  I'hroat 
Journal  of  Laryngology. 
Mackenzie.  1  he  (Jisopnagus, 
Naso-Pharynx,  etc. 

Pharmacopceia.    - 

Murrell.     Bronchitis. 
Potter.     Stammering,  etc. 
Woakes.  Post-Nasal  Catarrh. 

Nasal  Polypus,  etc. 

Deafness,  Giddiness,  etc. 


5.00 

1.25 

1-75 
3.0U 
2.25 
1.25 
5" 
2.00 
I.oo 
5.00 

•75 
3.00 

•S° 
1.25 
1.25 
1.25 

3.00 

3.00 
1.25 

1.50 
I.oo 
1.50 
I  25 


TRANSACTIONS  AND 

REPORTS. 

Penna.  Hospital  Reports,      1.15 

Power  and  Holmes'  Keports.   1.25 

Trans.  College  of  Physicians.  3.50 

Amer.  Surg.  Assoc.        3  co 

Assoc.  Amer.  Phys,   3.50 

URINE  &  URINARY  ORGANS, 
Acton.     Repro.  Organs.  2.00 

Beale,     Urin.  &  Renal  Dis.      1.75 
Urin.  Deposits.    Plates.  2.00 


Holland.  The  Urine  and  Com- 
mon Poisons.     3d  Ed.      -        1.00 
Legg.     On  Urine.     -        -  .75 

MacMunn.  Chem.  of  Urine,  3.00 
Marshall  and  Smith.  Urine.  1.00 
Ralfe.  Kidney  and  Uri.  Org.  2.75 
Schnee.     Diabetes.  -        2.i.,o 

Thompson.  Urinary  Organs.   3.50 

Surg,  of  Urin.  Organs.    1.25 

Calculous  Dis.  3d.  Ed.    i.oo 

Lithotomy.     -        -  3.50 

Prostate.     6th  Ed.  2.00 

Tyson.  Exam,  of  Urine,  i.go 
Van  NUys.    Urine  Analysis.    2.00 

VENEREAL  DISEASES. 
Cooper.     Syphilis.  -        -  3.50 

Durkee.     Gonorrhoea.     -  3.50 

Hill  and  Cooper's  Manual,  i.oo 
Lewin.     Syphilis.  Pa.  75;  Clo.  1.25 

VISITING   LISTS. 
Lindsay    and     Blakiston's 
Regular   Edition.     Send  /or 
Circular.        -        -      i.oo  to  3.00 

Perpetual  Edition.  1.25 

Monthly  Ed. 

Plain,  .75;  Tucks,  i.oo 

WATER. 
Fox,     Water,  Air,  Food.  4.00 

Frankland.     Analysis  of.  i.oo 

Leffmann&  Beam.  Exam.  of.  1.25 
MacDonald.     Analysis  of.       2.75 

WOMEN,  DISE.A.SES  OF. 
Byford's  I'ext-book.  4th  Ed.   5.00 

Uterus.  .        -         -  1.25 

Dillnberger.  and  Children.  1.50 
Doran.  Gyna;c.  Operations.  4.50 
Hodge,  'luniors.  Note  Book  .50 
Lewers.  Dis.  of  Women.  2.25 
Morris.     Compend.  -  i.oo 

Scanzoni.  Sexual  Organs  of.  4.00 
Tilt.     Change  of  Life.      -  1.25 

Winckel,  by  Parvin.    Manual 

of.     lllus.        Clo.,  3.00  ;  Sh.  3.50 


New  Text-Books. 


Macalister's  Human  Anatomy.     8i6  Illustrations  (400  of 
which  are  Original).     Just  Ready. 

A  NEW  TEXT-BOOK  for  Students  and  Practitioners,  Systematic  and  Topographical, 
including  the  Embryology,  Histology  and  Morphology  of  Man.  With  special 
reference  to  the  requiremeuts  of  Practical  Surgery  and  Medicine. 
By  Alex.  Macalister,  m.d.,  f.r.s.,  f.s.a.,  Professor  of  Anatomy  in  the  Univer- 
sity of  Cambridge,  England;  Examiner  in  Zoology  and  Comparative  Anatomy, 
University  of  London;  formerly  Professor  of  Anatomy  and  Surgery,  University 
of  Dublin.     With  8i6  Illustrations,  400  of  which  are  original.     Octavo. 

Cloth,  $7.50;  Leather,  $8.50 

*ji.*  Professor  Macalister's  reputation  as  an  Anatomist  and  Zoologist  is  such  that 
nothing  need  be  said  of  the  scientific  value  of  this  book.  Regarding  the  illustrations, 
printing  and  binding  we  may  say,  however,  that  the  workmanship  is  of  the  best 
character  in  every  respect.  No  expense  has  been  spared  to  make  a  handsome  vol- 
ume, the  400  original  illustrations  adding  greatly  to  its  appearance  as  well  as  to  its 
practical  value  as  a  working  book  for  students  and  physicians. 

Potter's  Materia  Medica,  Pharmacy  and  Therapeutics. 
Second  Edition.     Revised  and  Enlarged. 

a  handbook  of  materia  medica,  phakmacy  and  therapeutics — including 
the  Physiological  Action  of  Drugs,  Special  Therapeutics  of  Diseases,  Official  and 
Extemporaneous  Pharmacy,  etc.  By  Sam'l  O.  L.  Potter,  m.a.,  m.d.,  Professor 
of  the  Practice  of  Medicine  in  Cooper  Medical  College,  San  Francisco;  Late 
A.  A.  Surgeon,  U.  S.  Army,  Author  of  "  Speech  and  its  Defects,"  and  the  "Quiz- 
Compends"  of  Anatomy  and  Materia  Medica,  etc.  Revised,  Enlarged  and  Im- 
proved.    Octavo.      With  Thumb  Index  in  each  copy. 

Cloth,  $4.00;  Leather,  $5.00 

"  The  author  has  aimed  to  embrace  in  a  single  volume  the  essentials  of  practical  materia 
medica  and  therapeutics,  and  has  produced  a  book  small  enough  for  easy  carriage  and  easy  ref- 
erence, large  enough  to  contain  a  carefully  digested,  but  full,  clear  and  well-arranged  mass  of 
information.  He  has  not  adhered  to  any  pharinacopaia,  as  is  the  case  of  certain  recent  manuals, 
thereby  limiting  his  work,  and  in  this  day  of  new  remedies  causing  Constant  disappointment,  but 
has  brought  it  up  to  dale  in  the  most  satisfactory  way.  No  new  remedy  of  any  acknowledged 
value  is  omitted  from  this  list.  Under  each  the  section  on  physiological  action  and  therapeutics 
has  been  written  with  care.  ...  In  the  enumeration  ot  drugs  suited  to  different  dis  .rders  a 
very  successful  effort  at  discrimination  has  been  made,  both  in  the  stage  of  disease  and  in  the 
cases  peculiarly  suited  to  the  remedy.  It  is  no  mere  list  of  diseases  followed  by  a  catalogue 
of  drugs,  but  is  a  digest  of  modern  therapeutics,  and  as  such  will  prove  of  immense  use  to  its 
possessor." — The  1  ht'rapeulic  Gazette. 

Winckel's  Obstetrics.     Original  Illustrations. 

A  TEXT-BOOK   OF   OBSTETRICS,  INCLUDING   THE   PATHOLOGY   AND   THERAPEUTICS 

OF  THE  PUERPERAL  STATE.  By  Dr.  F.  Winckel,  Professor  of  Gynzecology, 
and  Director  of  the  Royal  University  Clinic  for  Women,  in  Munich.  Authorized 
Translation,  by  J.  Clifton  Edgar,  m.d..  Adjunct  Professor  to  the  Chair  of 
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ACTON.  The  Functions  and  Disorders  of  the  Reproductive  Organs  in  Child- 
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BAR.  Antiseptic  Midwifery.  The  Principles  of  Antiseptic  Methods  Applied  to 
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BARRETT.  Dental  Surgery  for  General  Practitioners  and  Students  of  Medicine 
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5 


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BARTLEY.  Medical  Chemistry.  Second  Edition.  A  Text-book  for  Medical  and 
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BEALE.    On  Slig-ht  Ailments ;  their  Nature  and  Treatment.     By  Lionel  S.  Beale, 

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BURNETT.  Hearing,  and  How  to  Keep  It.  By  Chas.  H.  Burnett,  m.d.,  Prof, 
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BYFORD.  Diseases  of  "Women.  The  Practice  of  Medicine  and  Surgery,  as 
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CARPENTER.    The  Microscope  and  Its  Revelations.    By  W.  B.  Carpenter, 

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tions and  Lithographs.  Nciu  Edition  in  Press. 

CAZEAUX  and  TARNIER'S  Midwifery.  With  Appendix,  by  Munde.  Eighth 
Revised  and  Enlarged  Edition.  With  Colored  Plates  and  numerous  other 
Illustrations.  The  Theory  and  Practice  of  Obstetrics  ;  including  the  Diseases 
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by  S.  Tarnier,  m.d.,  Professor  of  Obstetrics  and  Diseases  of  Women  and 
Children  in  the  Faculty  of  Medicine  of  Paris.  Eighth  American,  from  the 
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and  Two  Colored  Lithographs.     8vo.  Cloth,  S3. 50 

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CROOKSHANK.  History  and  Pathology  of  Vaccination.  In  two  volumes. 
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CROCKER.  Diseases  of  the  Skin.  Their  Description,  Pathology,  Diagnosis  and 
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CTJLLINGWORTH.    A  Manual  of  Nursing,  Medical  and  Surgical.    By  Charles 

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FAGGE.  The  Principles  and  Practice  of  Medicine.  By  C.  Hilton  Fagge,  m.d., 
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and  Lecturer  on  Pathology  in,  Guy's  Hospital ;  Senior  Physician  to  Evelina  Hos- 
pital for  Sick  Children,  etc.  Arranged  for  the  press  by  Philip  H.  Pye  Smith, 
M.D.,  Lect.  on  Medicine  in  Guy's  Hospital.  Including  a  section  on  Cutaneous 
Affections,  by  the  Editor ;  Chapter  on  Cardiac  Diseases,  by  Samuel  Wilkes,  m.d., 
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FILLEBROWN.  A  Text-Book  of  Operative  Dentistry.  Written  by  invitation 
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versity ;  Member  of  the  American  Dental  Assoc,  etc.    lUus.    8vo.      Clo.,  $2.50 

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of  the  Cutaneous  Surface  and  to  all  the  Muscles.  By  William  H.  Flower, 
f.r.c.s.,  F.R.S.,  Hunterian  Professor  of  Comparative  Anatomy,  and  Conservator 
of  the  Museum  of  the  Royal  College  of  Surgeons.  Third  Edition,  thoroughly 
revised.     With  six  Large  Folio  Maps  or  Diagrams.     4to.  Cloth,  ;?3.5o 

FLUCKIGER.  The  Cinchona  Barks  Pharmacognostically  Considered.  By 
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FOTHERGILL.  On  the  Heart  and  Its  Diseases.  With  Their  Treatment.  In- 
cluding the  Gouty  Heart.  By  J.  Milner  Fothergill,  m.d..  Member  of  the 
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FOX   AIJD   GOULD.     Compend  on  Diseases  of  the  Eye  and  Refraction, 

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Assistant,  Ophthalmological  Department,  Jefferson  Medical  College  Hospital ; 
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at  Moorfields,  London,  England,  etc.,  and  Geo.  M.  Gould,  m.d.  Second  Edition. 
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GOULD'S  New  Medical  Dictionary.  Including  all  the  Words  and  Phrases  used 
in  Medicine,  with  their  proper  Pronunciation  and  Definitions,  based  on  Recent 
Medical  Literature.  By  George  M.  Gould,  b.a.,  m.d.,  Ophthalmic  Surgeon  to 
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London.  Physician  to  National  Hospital  for  the  Paralyzed  and  Epileptic.  341 
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Diagnosis  of  Diseases  of  the  Spinal  Cord.    4th  Edition.  Preparhii^. 

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Lithograph  Plates  of  Original  Drawings,  Wood  Cuts,  etc.  3d  Edition, 
revised  by  Dr.  W.  S.  Colman.     Octavo.  In  I^ess. 

Syphilis  and  the  Nervous  System.  Being  the  Lettsomanian  Lectures  for 
1889.     8vo.  In  Press. 

GROSS'S  Biography  of  John  Hunter.  John  Hunter  and  His  Pupils.  By  Profes- 
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GREENHOW.  Addison's  Disease.  Illustrated  by  Plates  and  Reports  of  Cases. 
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Chronic  Bronchitis,  especially  as   connected  with  Gout,  Emphysema,  an 
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GROVES  AND  THORP.  Chemical  Technology.  A  new  and  Complete  Work. 
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umes, with  numerous  illustrations.     Each  volume  sold  separately. 

Vol.  I.  Fuel.  By  Dr.  E.  J.  Mills,  f.r.s.,  Professor  of  Chemistry,  Anderson 
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HABERSHON.    On  Some  Diseases  of  the  Liver.    By  S.  O.  Habershon,  m.d., 

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HADDON'S  Embryology.  An  Introduction  to  the  Study  of  Embryology.  For 
the  Use  of  Students.  By  A.  C.  Haddon,  m.a.,  Prof,  of  Zoology,  Royal  College 
of  Science,  Dublin.     190  Illustrations.  Cloth,  6.00 

HALE.  On  the  Management  of  Children  in  Health  and  Disease.  A  Book  for 
Mothers.     By  Amie  M.  Hale,  m.d.     New  Enlarged  Edition.     i2mo.     Cloth,  .75 

HARE.  Mediastinal  Disease.  The  Pathology,  Clinical  History  and  Diagnosis  of 
Affections  of  the  Mediastinum  other  than  those  of  the  Heart  and  Aorta,  with 
tables  giving  the  Clinical  History  of  520  cases.  The  essay  to  which  was  awarded 
the  Fothergillian  Medal  of  the  Medical  Society  of  London,  18S8.  By  H.  A. 
Hare,  m.d.  (Univ.  of  Pa.),  Demonstrator  of  Therapeutics  and  Instructor  in  Phy- 
sical Diagnosis  in  the  Medical  Department,  and  Instructor  in  Physiology  in  the 
Biological  Department,  Univ  of  Pa.    Bvo.    Illustrated  by  Six  Plates.     Cloth,  $2.00 

HARLAN.  Eyesight,  and  How  to  Care  for  It.  By  George  C.  Harlan,  m.d., 
Prof,  of  Diseases  of  the  Eye,  Philadelphia  Polyclinic.     Illustrated.         Cloth,  .50 

HARLEY.  Diseases  of  the  Liver,  With  or  Without  Jaundice.  Diagnosis  and 
Treatment.  By  George  Harley,  m.d.  With  Colored  Plates  and  Numerous 
Illustrations.     8vo.  Price  reduced.     Cloth,  $3.00  ;  Leather,  1:4.00 

HARRIS.  On  the  Chest.  Including  the  Principal  Affections  of  the  Pleura;,  Lungs, 
Pericardium,  Heart  and  Aorta.  By  Vincent  D.  Harris,  f.r.c.p..  Physician  to 
the  Victoria  Park  Hospital  for  Diseases  of  the  Chest,  London.  With  55  Illus- 
trations. Cloth,  $2.50 

HARRIS'S  Principles  and  Practice  of  Dentistry.    Including  Anatomy,  Physi- 
ology, Pathology,  Therapeutics,  Dental  Surgery  and  Mechanism.     By  Chapin  A. 
Harris,  m.d.,  d.d.s.,  late  President  of  the  Baltimore  Dental  College,  author  ot 
"Dictionary  of  Medical  Terminology  and  Dental  Surgery."     Twelfth  Edition. 
Revised  and  Edited  by  Ferdinand  J.  S.  Gorgas,  a.m.,  m.d.,  d.d.s.,  author  of 
"Dental   Medicine;"    Professor  of  the  Principles   of   Dental   Science,   Dental 
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Plates  and  1086  Illustrations.     1225  pages.    8vo.        Cloth,  $7.00;  Leather,  ;^8.oo 
Medical  and  Dental  Dictionary.    A  Dictionary  of  Medical  Terminology, 
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Revised  and  Enlarged.     By  Ferdinand  J.  S.  Gorgas,  m.d.,  d.d.s..  Prof,  of 
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12  P.  BLAKISTON,  SON  &*  CO.'S 


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By  GusTAVi'S  Haktriijoe,  f.r.c.s.,  Consulting  Ophthalmic  Surgeon  to  St.  Bar- 
tholomew's Hospital ;  Ass't  Surgeon  to  the  Royal  Westminster  Ophthalmic  Hos- 
pital, etc.     96  Illustrations  and  Test  Types.     Fourth  Edition.  Cloth,  J2.00 

HARTSHORNE.  Our  Homes.  Their  Situation,  Construction,  Drainage,  etc.  By 
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HEADLAND'S  Action  of  Medicines.  On  the  Action  of  Medicines  in  the  System. 
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HEATH'S   Operative  Surgery.     A  Course  of  Operative  Surgery,  consisting  of  a 

Series  of  I'lates,  Drawn  from  Nature  by  M.  Leveille,  of  Paris.    With  Descriptive 

Text  of  Each  Operation.     By  Christopher  Heath,  f.r.c.s.,  Flolme  Professor 

of  Clinical  Surgery  in  University  College,  London.     Quarto.     Second  Edition. 

Revised.     Sold  by  Subsc7-ipiiofi.  Cloth,  $12.00 

Minor  Surgery  and  Bandaging.    Ninth  Edition.    Revised  and  Enlarged. 

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Practical  Anatomy.     A  Manual  of  Dissections.     Seventh  London   Edition. 

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Injuries  and  Diseases  of  the  Jaws.  Third  Edition.  Revised,  with  over 
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HENRY.  Anaemia.  A  Practical  Treatise.  By  Fred'k  P.  Henry,  m.d..  Prof. 
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HILLIER.    Diseases  of  Children.    A  Clinical  Treatise.    By  Thomas  Hillier, 
M.D.     8vo.  Cloth,  $1.25 

HILL  AND  COOPER.  Venereal  Diseases.  The  Student's  Manual  of  Venereal 
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By  Berkeley  Hill,  m.d.,  Professor  of  Clinical  Surgery,  University  College,  and 
Arthur  Cooper,  m.d.,  Late  House  Surgeon  to  the  Lock  Hospital,  London. 
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HOLDEN'S  Anatomy.  A  Manual  of  the  Dissections  of  the  Human  Body.  By 
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Specially  concerning  the  Anatomy  of  the  Nervous  System,  Organs  of  Special 
Sense,  etc.  By  John  Langton,  f.r.c.s..  Surgeon  to,  and  Lecturer  on  Anatomy 
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Landmarks.     Medical  and  Surgical.     4th  Edition.     8vo.  Cloth,  $1.25 

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HOLLAND.  The  Urine,  the  Common  Poisons  and  the  Milk.  Memoranda,  Chem- 
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HORWITZ'S  Compend  of  Surgery,  including  Minor  Surgery,  Amputations,  Frac- 
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Differential  Diagnosis  and  Treatment.  By  Orville  Hokwitz,  b.s.,  m.d.,, Dem- 
onstrator of  Anatomy,  Jefferson  Medical  College ;  Chief,  Out-Patient  Surgical 
Department,  Jefferson  Medical  College  Hospital.  Third  Edition.  Very  much 
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scopical Anatomy,  with  special  reference  to  the  requirements  of  Practical  Medi- 
cine. By  Dr.  L.  Landois,  Professor  of  Physiology  and  Director  of  the  Physio- 
logical Institute  in  the  University  of  Greifswald.  Third  American,  translated 
from  the  Sixth  German  Edition,  with  additions,  by  Wm.  Stirling,  m.d.,  d.Sc., 
Brackenbury  Professor  of  Physiology  and  Histology  in  Owen's  College.  Man- 
chester;  Examiner  in  Physiology  in  University  of  Oxford,  England.  With  692 
Illustrations.     8vo.  Cloth,  $6.50;  Leather,  J7. 50 

LEBER  AND  ROTTENSTEIN.  Dental  Caries  and  Its  Causes.  An  Investigation 
into  the  Influence  of  Fungi  in  the  Destruction  of  the  Teeth.  By  Drs.  Leber 
and  Rottenstein.     Illustrated.  Paper,  .75  ;  Cloth,  ;ni. 25 


14  P.  BLAKISTON,  SON  6-  CO:S 

LEE.  The  Microtomist's  Vade  Mecum.  Second  Edition.  By  Arthur  Bolles  Lee. 
A  Handbook  of   Methods  of  Microscopical  Anatomy.     660  Formulae,  etc. 

In  Press. 

LEFFMANN'S  Compend  of  Chemistry,  Inorganic  and  Organic.  Including  Urine 
Analysis  and  the  Analysis  of  Water.  By  Henry  Leffmann,  m.d.,  Prof,  of 
Chemistry  and  Metallurgy  in  the  Penna.  College  of  Dental  Surgery,  and  in  the 
Wagner  Free  Institute  of  Science,  Philadelphia.  No.  10  ? (2uiz- Compend ? 
Series.  Second  Edition.  Rewritten  and  Adapted  for  Students  of  Medicine  and 
Dentistry.     i2mo.  Cloth,  $1.00.     Interleaved  for  the  addition  of  Notes,  $1.25 

LEFFMANN  &  BEAM.  Examination  of  "Water  for  Sanitary  and  Technical  Pur- 
poses. By  Henry  Leffmann,  m.d.,  Professor  of  Chemistry  and  Metallurgy, 
Penna.  College  of  Dental  Surgery,  Hygienist  and  Food  Inspector  Penna.  State 
Board  of  Agriculture,  etc.;  and  William  Beam,  a.m.,  formerly  Chief  Chemist 
B.  &  O.  R.  R.     Illustrated.     i2mo.  Cloth,  Si-25 

LE6G  on  the  Urine.  Practical  Guide  to  the  Examination  of  the  Urine,  for 
Practitioner  and  Student.  By  J.Wickham  Legg,  m.d.  Sixth  Edition,  Enlarged. 
Illustrated.     i2mo.  Cloth,  .75 

LEWERS.  On  the  Diseases  of  Women.  With  over  120  Engravings.  Practical 
Series.     See  Page  ig.     i2mo.  Cloth,  $2.25 

LEWIN  on  Syphilis.  The  Treatment  of  Syphilis.  By  Dr.  George  Lewin,  of 
Berlin.  Translated  by  Carl  Proegler,  m.d.,  and  E.  H.  Gale,  m.d..  Surgeons 
U.  S.  Army.     Illustrated.     i2mo.  Paper,  .75  ;  Cloth,  $1.25 

LEWIS,  (BEVAN).  Mental  Diseases.  A  text-book  having  special  reference  to  the 
Pathological  aspects  of  Insanity.  By  Bevan  Lewis,  l.k.c.p.,  m.r.c.s..  Medi- 
cal Director,  West  Riding  Asylum,  Wakefield,  England.  18  Lithographic  plates 
and  other  Illustrations.     8vo.  Cloth,  $6.00 

LIEBREICH'S  Atlas  of  Ophthalmoscopy,  composed  of  12  Chromo-Lithographic 
Plates  (containing  59  Figures),  with  Text.  Translated  by  H.  R.  Swanzy,  m.d. 
Third  Edition.     4to.  Boards.  Ji 5.00 

LINCOLN.    School  and  Industrial  Hygiene.    By  D.  F.  Lincoln,  m.d.    Cloth,  .50 

LONGLEY'S  Pocket  Medical  Dictionary  for  Students  and  Physicians.  Giving 
the  Correct  Definition  and  Pronunciation  of  all  Words  and  Terms  in  General 
Use  in  Medicine  and  the  Collateral  Sciences,  with  an  Appendix,  containing 
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Scale  of  Doses.     By  Elias  Longley.         Cloth,  $1.00;  Tucks  and  Pocket,  $1.25 

LIZARS,  (JOHN).     On  Tobacco.     The  Use  and  Abuse  of  Tobacco.  Cloth,  .50 

LUCKES.  Hospital  Sisters  and  their  Duties.  By  Eva  C.  E.  Lvckes,  Matron  to 
the  London  Hospital ;  Author  of"  Lectures  on  Nursing."     i2mo.       Cloth,  Si.oo 

MAC  MUNN.  Chemistry  of  Urine.  Illustrated.  Outlines  of  the  Clinical 
Chemistry  of  Urine.  By  C.  A.  Mac  Munn,  m.a.,  m.d.,  Dublin.  Sixty-four  Wood- 
cuts and  Plate  of  Spectra.  Octavo.  ?3-CO 
On  the  Spectroscope  in  Medicine.  With  3  Chromo-Iithographic  Plates  of 
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MACNAMARA.  On  the  Eye.  A  Manual  of  the  Diseases  of  the  Eye.  By  C. 
Macnamara,  m.d.  Fourth  Edition,  Carefully  Revised ;  with  Additions  and 
Numerous  Colored  Plates,  Diagrams  of  Eye,  Wood-cuts,  and  Test  Types. 
Demi  8vo.  Cloth,  $4.00 

MACALISTER'S  Human  Anatomy.  800  Illustrations.  A  New  Text-book  for 
Students  and  Practitioners.  Systematic  and  Topographical,  including  the 
Embryology,  Histology  and  Morphology  of  Man.  With  special  reference  to  the 
requirements  of  Practical  Surgery  and  Medicine.  By  Alex.  Macalister,  m.d., 
F.R.S.,  Professor  of  Anatomy  in  the  University  of  Cambridge,  England ;  Examiner 
in  Zoology  and  Comparative  Anatomy,  University  of  London  ;  formerly  Professor 
of  Anatomy  and  Surgery,  University  of  Dublin.  With  816  Illustrations,  400  ol 
which  are  original.     Octavo.  Cloth,  $7.50;  Leather.  $8.50 

*j,*  Professor  Macalister's  reputation  as  an  Anatomist  anci  Zoologist  is  such  that  nothing  need  be  said  of  the 
scientific  value  of  this  book.  Regarding  the  illustrations,  printing  and  binding  we  may  say,  h  wever,  that  the 
workmanship  is  of  the  best  character  in  every  respect.  No  expense  has  been  spared  to  make  a  handsome  vol- 
ume :  the  400  original  illustrations  adding  greatly  to  its  appearance  as  well  as  to  its  practical  value  as  a  working 
book  for  students 


MEDICAL  AND  SCIENTIFIC  PUBLICATIONS.  15 


MACDONALD'S  Microscopical  Examinations  of  Water  and  Air.  A  Guide  to  the 
Microscopical  Examination  of  Drinking  Water,  with  an  Appendix  on  the  Micro- 
scopical Examination  of  Air.  By  J.  D.  Macdonald,  m.d.  With  25  Litho- 
graphic Plates,  Reference  Tables,  etc.   Second  Ed.,  Revised.     8vo.    Cloth,  $2.75 

MACKENZIE.  The  (Esophagus,  Nose,  Naso-Pharynx,  etc.  By  Sir  Morell 
Mackenzie,  m.d.,  Senior  Physician  to  the  Hospital  for  Diseases  of  the  Chest 
and  Throat,  London.  Illus.  Being  Vol.  II  of  the  First  Edition  of  his  Treatise 
on  the  Throat  and  Nose.     Complete  in  itself.  Cloth,  $3.00;  Leather,  $4.00 

The  Pharmacopoeia  of  the  Hospital  for  Diseases  of  the  Throat  and  Nose. 
Fourth  Edition,  Enlarged,  Containing  250  Formulae,  with  Directions  for  their 
Preparation  and  Use.     i6mo.  Cloth,  $1.25 

MANN'S  Manual  of  Psychological  Medicine  and  Allied  Nervous  Diseases.  Their 
Diagnosis,  Pathology,  Prognosis  and  Treatment,  including  their  Medico-Legal 
Aspects  ;  with  chapter  on  Expert  Testimony,  and  an  abstract  of  the  laws  relating 
to  the  Insane  in  all  the  States  of  the  Union.  By  Edward  C.  Mann,  m.d., 
member  of  the  New  York  County  Medical  Society.  With  Illustrations  of  Typical 
Faces  of  the  Insane,  Handwriting  of  the  Insane,  and  Micro-photographic  Sec- 
tions of  the  Brain  and  Spinal  Cord.     Octavo.  Cloth,  $5.00;  Leather  $6.00 

MARSHALL  &  SMITH.  On  the  Urine.  The  Chemical  Analysis  of  the  Urine. 
By  John  Marshall,  m.d.,  and  Prof.  Edgar  F.  Smith,  of  the  Chemical  Labora- 
tories, University  of  Pennsylvania.     Phototype  Plates.     i2mo.  Cloth,  $1.00 

MASON'S  Compend  of  Electricity,  and  its  Medical  and  Surgical  Uses.  By 
Charles  F.  Mason,  m.d..  Assistant  Surgeon  U.  S.  Army.  With  an  Intro- 
duction by  Charles  H.  May,  m.d.,  Instructor  in  the  New  York  Polyclinic. 
Numerous  Illustrations.     i2mo.  Cloth,  $1.00 

MAYS'  Therapeutic  Forces  ;  or,  The  Action  of  Medicine  in  the  Light  of  the  Doc- 
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MEADOWS'  Obstetrics.  A  Text-Book  of  Midwifery.  Including  the  Signs  and 
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tion.    Revised  and  Enlarged.     With  145  Illustrations.     8vo.  Cloth,  $2.00 

MEDICAL  Directory  of  Philadelphia  and  Camden,  1889.  Containing  lists  of 
Physicians  of  all  Schools  of  Practice,  Dentists,  Veterinarians,  Druggists  and 
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tions, Hospitals,  Asylums,  Charities,  etc.  Morocco,  Gilt  edges,  $2.50 

MEIGS.  Milk  Analysis  and  Infant  Feeding.  A  Practical  Treatise  on  the  Ex- 
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MEIGS  and  PEPPER  on  Children.  A  Practical  Treatise  on  the  Diseases  of 
Children.  By  J.  FoRSYTH  Meigs,  m.d..  Fellow  of  the  College  of  Physicians  of 
Philadelphia,  etc.,  etc.,  and  William  Pepper,  m.d.,  Professor  of  the  Principles 
and  Practice  of  Medicine  in  the  Medical  Department,  University  of  Pennsyl- 
vania.    Seventh  Edition.  Cloth,  $5.00;  Leather,  $6.00 

MERRELL'S  Digest  of  Materia  Medica.  Forming  a  Complete  Pharmacopoeia  for 
the  use  of  Physicians,  Pharmacists  and  Students.  By  Albert  Merrell,  m.d. 
Octavo.  Half  dark  Calf,  §4.00 

MEYER.  Ophthalmology.  A  Manual  of  Diseases  of  the  Eye.  By  Dr.  Edouard 
Meyer,  Prof,  a  L'l^cole  de  la  Faculte  de  Medicine  de  Paris,  Chev.  of  the  Legion 
of  Honor,  etc.  Translated  from  the  Third  French  Edition,  with  the  assistance 
of  the  author,  by  A.  Freedland  Fergus,  m.b..  Assistant  Surgeon  Glasgow 
Eye  Infirmary.  With  270  Illustrations,  and  two  Colored  Plates  prepared 
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of  Ophthalmoscopy."     8vo.  Cloth,  $4.50;  Leather,  $5.50 


16  P.  BLAKISTON,  SON  &'  CO:S 


MILLER  and  LIZAR'S  Alcohol  and  Tobacco.  Alcohol.  Its  Place  and  Power. 
By  James  MiLLiiU,  f.r.c.s.  ;  and,  Tobacco.  Us  Use  and  Abuse.  By  John  Lizaks. 
M.D.     The  two  essays  in  one  volume.  Cloth,  $i.oo;  Separate,  each  .50 

MILLS.  Fuel  and  Its  Applications.  By  E.  J.  Mills,  d.sc.  f.r.s..  and  E.  J. 
Rowan,  c.e.  (See  Groves  and  Thorp  Technology.)  8vo.  Clo.,  $7.50;  Half  Mor.  $9.00 

MONEY.  On  Children.  Treatment  of  Disease  in  Children,  including^  the  Outlines 
of  Dia<Tnosis  and  the  Chief  Patholog^ical  Differences  between  Children  and 
Adults.  By  Angel  Money,  m.d.,  m.r.c.p.,  Asst.  Physician  to  the  Hospital  for 
Sick  Children,  Great  Ormond  St.,  and  to  the  Victoria  Park  Chest  Hospital,  Lon- 
don.    Practical  Series.     See  Pai^e  ig.     i2mo.     560  pages.  Cloth,  $3.00 

MORRIS.  Compend  of  Gynaecology.  By  Henry  Morris,  m.d..  Demonstrator  of 
Obstetrics,  Jefferson  Medical  College,  Phila.,  etc.  Being  f  Quiz- Compend  f 
j\Jo.  7.  Nearly  Ready 

MORTON  on  Refraction  of  the  Eye.  Its  Diagnosis  and  the  Correction  of  its  Errors. 
With  Chapter  on  Keratoscopy,  and  Test  Types.  By  A.  Morton,  m.b.  Third 
Edition,  Revised  and  Enlarged.  Cloth,  $1.00 

MTTRRELL.  Massotherapeutics.  Massage  as  a  Mode  of  Treatment.  By  Wm. 
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minster Hospital.     4th  Edition.    Revised.    i2mo.  Cloth,  $1.50 

Chronic  Bronchitis  and  its  Treatment.    A  Clinical  Study.    i2mo.    176 
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MUTER.  Practical  and  Analytical  Chemistry.  By  John  MiJter,  f.r.s.,  f.c.s., 
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NEW  SYDENHAM  SOCIETY  Publications.  Three  to  Six  Volumes  published 
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OBERSTEINER,  The  Central  Nervous  System.  A  Guide  to  the  study  of  their 
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sity  of  Vienna.  Translated,  with  annotations  and  additions,  by  Alex.  Hill,  M. A., 
M.D.,  IMaster  of  Downing  College,  Cambridge.  Numerous  Illustrations.  In  Press- 

OPHTHALMIC  REVIEW.  A  Monthly  Record  of  Ophthalmic  Science.  Published 
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etc.     8vo.  Cloth,  $2.00 

OSTROM.  Massage  and  the  Original  Swedish  Movements.  Their  Application 
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Bv  Kurre  W.  Ostrom,  from  the  Royal  University  of  Upsala,  Sweden;  Instructor 
in  Massage  and  Swedish  Movements  in  the  Hospital  of  the  University  of 
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MEDICAL  AND  SCIENTIFIC  PURLICA  TIONS.  17 

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18  P.  BLAKISTON.  SON  6^  CO.'S  PUBLICA  TIONS. 

POWER,  HOLMES,  ANSTIE  and  BARNES  (Drs.).  Reports  on  the  Progress  of 
Medicine,  Surgery,  Physiology,  Midwifery,  Diseases  of  Women  and  Children. 
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POTTER.  A  Handbook  of  Materia  Medica,  Pharmacy  and  Therapeutics,  in- 
cluding the  Action  of  Medicines,  Special  Therapeutics,  Pharmacology,  etc.  In- 
cluding over  600  Prescriptions  and  Formulae.  By  Samuel  O.  L.  Potter,  m.a., 
M.D.,  Professor  of  the  Practice  of  Medicine,  Cooper  Medical  College,  San  Fran- 
cisco ;  late  A.  A.  Surgeon  U.  S.  Army.  Second  Edition,  Revised  and  Enlarged. 
8vo.      With  Thumb  Index  171  each  copy.  Cloth,  $4.00;  Leather,  $5.00 

Speech  and  Its  Defects.  Considered  Physiologically,  Pathologically  and 
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Revised  and  Corrected.     i2mo.  Cloth,  $1.00 

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PRITCHARD  on  the  Ear.  Handbook  of  Diseases  of  the  Ear.  By  Urban 
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RICHARDSON.  Long  Life,  and  How  to  Reach  It.  By  J.  G.  Richardson,  Prof, 
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RICHARDSON'S  Mechanical  Dentistry.  A  Practical  Treatise  on  Mechanical 
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THE   PRACTICAL  SERIES. 

THREE  NEW  VOLUMES. 


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1 39  Engravings.  Second  Edition  in  Press. 

BTJXTOII.  On  Anaesthetics.  A  Manual  of  their  Uses  and  Administration.  By 
Dudley  Wilmot  Buxton,  m.d.,  b.s.,  Ass't  to  Prof,  of  Med.,  and  Administrator 
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Second  Edition  in  Press. 


MONEY.  On  Children.  Treatment  of 
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lines of  Diagnosis  and  the  Chief 
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PRITCHARB.  On  the  Ear.  Handbook 
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ise on  Fevers,  Their  History,  Etiology. 
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REEVES.     Bodily    Deformities    and 

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RICHTER'S  Inorganic  Chemistry.  A  Text-book  for  Students.  By  Prof.  Victor 
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ROBERTS.     Practice  of  Medicine.     The  Theory  and  Practice  of  Medicine.     By 

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London.    Seventh  Edition,  with  Illustrations.    8vo.    Cloth,  5^5.50 ;  Leather,  56.50 

Materia  Medica  and  Pharmacy.    A  Compend  for  Students.        Cloth,  52.00 

ROBERTS.     The  Human  Brain.     The  Field  and  Limitation  of  the  Operative  Sur- 
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Crooked  and  Deformed  Noses.     Illustrated.    8vo.       Cloth,  .75;  Paper,  .50 

SANDERSON'S  Physiological  Laboratory.  A  Handbook  of  the  Physiological 
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/■ 

SCHNEE.  Diabetes,  its  Cause  and  Permanent  Cure.  From  the  standpoint  of  ex- 
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Edition,  Enlarged.     8vo.  Cloth,  53.00 

Clinical  Studies  of  Diseases  in  Children.    Second  Edition.       Cloth,  52.50 

SMITH.  Abdominal  Surgery.  Being  a  Systematic  Description  of  all  the  Princi- 
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SMITH  (TYLER).  Lectures  on  Obstetrics.  Delivered  at  St.  Mary's  Hospital. 
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STAMMER.  Chemical  Problems,  with  Explanations  and  Answers.  By  Karl 
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STARR  and  WALKER.  Physiological  Action  of  Medicines.  Prepared  for  the 
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Belfast  Union  Infirmary  and  Fever  Hospital.     Octavo.  Cloth,  gi.50 

SUTTON'S  Volumetric  Analysis.  A  Systematic  Handbook  for  the  Quantitative 
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geons;  Assistant  Surgeon  and  Demonstrator  of  Anatomy,  Middlesex  Hospital, 
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SWAYNE'S  Obstetric  Aphorisms,  for  the  Use  of  Students  commencing  Midwifery 
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SYMONDS.  Manual  of  Chemistry,  for  the  special  use  of  Medical  Students.  By 
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Index  of  Dental  Periodical  Literature.    Svo.  Cloth,  j;2.oo 

TALBOT.  Irregularities  of  the  Teeth,  and  Their  Treatment.  By  Eugene  S. 
'lALBOT,  M.D.,  Professor  of  Dental  Surgery  Woman's  Medical  College,  and 
Lecturer  on  Dental  Pathology  in  Rush  Medical  College,  Chicago.  Octavo.  150 
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22  P.  BLAKISTON,  SON  &-  CO.'S 

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Urinary  Organs.  Diseases  of  the  Urinary  Organs.  Containing  32  Lectures. 
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On  the  Prostate.  Diseases  of  the  Prostate.  Their  Pathology  and  Treatment. 
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THORBURN.  Surgery  of  the  Spinal  Cord.  A  Contribution  to  the  study  of.  By 
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TIDY.     Modern  Chemistry,  Inorganic  and  Organic.     A  Handbook  for  the  Use  of 

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TILT'S  Change  of  Life  in  Women,  in  Health  and  Disease.  A  Practical  Treatise 
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TOMES'  Dental  Anatomy.  A  Manual  of  Dental  Anatomy,  Human  and  Compara- 
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Dental  Surgery.  A  System  of  Dental  Surgery.  By  John  Tomes,  f.r.s. 
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istry in  the  Philadelphia  College  of  Pharmacy.  Second  Edition.  Enlarged. 
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TURNBULL'S  Artificial  Anaesthesia.  The  Advantages  and  Accidents  of  Artifi- 
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ministration ;  Considering  their  Relative  Risks  ;  Tests  of  Purity  ;  Treatment  of 
Asphyxia ;  Spasms  of  the  Glottis ;  Syncope,  etc.  By  Laurence  Turnbull,  m.d., 
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vised and  Enlarged.     40  Illustrations.     12010.  Cloth,  $3.00 

TUSON.  Veterinary  Pharmacopoeia.  Including  the  Outlines  of  Materia  Medica 
and  Therapeutics.  For  the  Use  of  Students  and  Practitioners  of  Veterinary 
Medicine.     By  Richard  V.  Tuson,  f.c.s.     Third  Edition.     i2mo.     Cloth,  $2.50 


MEDICAL  AND  SCIENTIFIC  PUBLICA  TIONS.  23 

TYSON.  Bright's  Disease  and  Diabetes.  With  Especial  Reference  to  Pathology 
and  Therapeutics.  By  James  Tyson,  m.d.,  Professor  of  Pathology  and  Morbid 
Anatomy  in  the  University  of  Pennsylvania.  Including  a  Section  on  Retinitis  in 
Bright's  Disease.  By  Wm.  F.  Norris,  m.d.,  Clin.  Prof,  of  Ophthalmology,  in  Univ. 
ofPenna.    With  Colored  Plates  and  many  Wood  Engravings.    8vo.    Cloth,  $3.50 

Guide  to  the  Examination  of  Urine.     Sixth.  Edition.     For  the  Use  of 

Physicians  and  Students.    With  Colored  Plates  and  Numerous  Illustrations 

Engraved  on  Wood.   Sixth  Edition.  Revised.   i2mo.   250  pages.   Cloth,  $1.50 

Cell  Doctrine.     Its  History  and  Present  State.     With  a  Copious  Bibliography 

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VALENTIN'S  Qualitative  Analysis.  A  Course  of  Qualitative  Chemical  Analysis. 
By  Wm.  G.Valentin,  F.c.s.  Seventh  Edition.  Illustrated.  Octavo.     Cloth,  $3.00 

VAN  HARLINGEN  on  Skin  Diseases.  A  Practical  Manual  of  Diagnosis  and 
Treatment.  By  Arthur  Van  Harlingen,  m.d.,  Professor  of  Diseases  of  the 
Skin  in  the  Philadelphia  Polyclinic ;  Clinical  Lecturer  on  Dermatology  at  Jef- 
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Eight  Colored  and  other  full  page  plates,  and  New  Illustrations.  Cloth,  2.50 

VAN  NUYS  on  The  TJrine.  Chemical  Analysis  of  Healthy  and  Diseased  Urine, 
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Indiana  University.     39  Illustrations.     Octavo.  Cloth,  ^2.00 

VIRCHOWS  Post-mortem  Examinations.     A  Description  and  Explanation  of  the 
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with  especial  reference  to  Medico-legal  Practice.     By  Prof.  Virchow.     Trans- 
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WALSHAM.  Manual  of  Practical  Surgery.  For  Students  and  Physicians.  By 
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WARNER.  Case  Taking.  A  Manual  of  CUnical  Medicine  and  Case  Taking.  By 
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WATSON  on  Amputations  of  the  Extremities  and  Their  Complications.  By 
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(Being  the  13th  Edition  of  Fowne's  Organic   Chemistry.)     Illustrated. 

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By  C.  J.  B.  Williams,  m.d.  Second  Edition.  Enlarged  and  Rewritten.  By  C. 
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Octavo.  Cloth,  5.00 


24  P.  BLAKISTON,  SON  &•  CO.'S  PUBLICATIONS. 

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eases of  the  Bladder  and  Urethra.  By  Dr.  F.  Winckel,  Professor  of 
Gynaecology,  and  Director  of  the  Royal  University  Clinic  for  Women,  in  iMunich. 
Translated  by  special  authority  of  Author  and  Publisher,  by  Dr.  J.  H.  William- 
son, Resident  Physician  of  Allegheny  General  Hospital,  Allegheny,  Pa.,  under 
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Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  Jefferson 
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WOAKES.     Post-Nasal  Catarrh,  and  Diseases  of  the  Nose,  causing  Deafness.     By 

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WOLFF.  Manual  of  Applied  Medical  Chemistry  for  Students  and  Practitioners  of 
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son Medical  College,  Philadelphia.  Cloth,  $1.00 

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Dose  and  Sjrmptom  Book.    The  Physician's  Pocket  Dose  and  Symptom  Book. 
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A  NEW  TEXT-BOOK  JUST  PUBLISHED. 

DISEASES  OF  THE  SKIN. 

BY  T.  MCCALL  ANDERSON,  M.D., 

Professor  of  Clinical  Medicine  in  the  University  of  Glasgow. 
ASSISTED  BY 
Dr.  James  Christie,  Sec'y  London  Epidemiological  Society  for  Indian  Ocean  and  East  Africa;  Men 
Medical  Soc.  of  Bombay,  etc.  Dr.  Hector  C.  Cameron,  Surgeon  and  Lecturer  to  Western  Infirmar; 
Glasgow;  Surgeon  to  Glasgow  Hospital  for  Children,  etc.  William  Macevven,  m.b.,  m.d.,  Lecturer  c 
Systematic  and  Clinical  Surgery,  Royal  Infirmary;  Surgeon  to  Royal  Infirmary  and  Children's  Hospita 
Glasgow,  etc. 

WITH  COLORED  PLATES  AND  NUMEROUS  WOOD  ENGRAVINGS. 

Octavo.     650  Pages.     Cloth,  $4.50  ;  Leather,  $5.50. 

A  treatise  on  Diseases  of  the  Skin,  with  reference  to  Diagnosis  and  Treatmeni 
including  an  Analysis  of  11,000  Consecutive  Cases.  Thoroughly  illustrated  by  new  an 
handsome  wood  engravings,  and  several  colored  and  steel  plates  prepared,  under  th 
direction  of  the  author,  from  special  drawings  by  Dr.  John  Wilson. 

PARTICULARLY  STRONG  IN  TREATMENT. 

J5@°"  Special  attention  is  given  to  the  Differential  Diagnosis  of  Skin  Diseases  and  to  tli 
treatment.  There  are  over  150  prescriptions,  which  will  serve  as  hints  to  the  physicia 
in  dealing  with  obstinate  and  chronic  cases. 

There  has  been  no  complete  treatise  on  Dermatology  issued  for  several  years  ;  Professc 
Anderson  has,  therefore,  chosen  an  opportune  time  to  publish  his  book. 


iLLtTSTRATING  ONE  OF  THE  DISEASES  OF  THE  HaiK  {^See  FlS-  b,page  j). 

For  nearly  twenty-five  years  Professor  Anderson  has  been  a  general  practitioner  and 
hospital  physician,  with  unusual  opportunities  for  the  study  of  this  class  of  diseases,  thoug 
not  a  "specialist,"  as  the  term  is  understood.  His  experience  is,  therefore,  of  grea 
value,  and  the  physician  will  feel  that,  in  consulting  this  work,  he  is  reading  the  exp( 
riences  of  a  man  situated  as  himself — with  the  same  difficulties  of  diagnosis  and  treatmeni 
and  who  has  surmounted  them  successfully.  We  believe  this  to  be  a  valuable  feature  c 
the  book  that  will  be  recognized  at  once;  for  it  is  undoubtedly  a  fact  that  a  work  lik 
the  present  contains  much  practical  information  and  many  hints  not  to  be  found  else 
where.  Professor  Anderson  is  particularly  happy  in  illustrating  the  impor 
tant  relations  subsisting  between  the  general  economy  and  its  covering,  ani 
his  ideas  of  pathology  and  therapeutics,  including  a  consideration  of  all  the  gener: 
and  local  manifestations  of  the  common  diseases  of  the  economy  which  are  manifeste 
upon  the  surface,  will  find  many  appreciative  readers. 

Diseases  of  the  hair  receive  full  systematic  treatment. 

"  We  welcome  Dr.  Anderson's  work  not  only  as  a  friend,  but  as  a  benefactor  to  the  profession,  because  the  author  h; 
stricken  off  mediaeval  shackles  of  insuperable  nomenclature  and  made  crooked  ways  straight  in  the  diagnosis  and  treaimeni  i 
this  hitherto  but  little  understood  class  of  diseases.  The  chapter  on  Eczema  is,  alone,  worth  the  price  of  the  book." — Aashznt 
Medical  Aews. 


New  Series  of  Manuals. 

FOR  MEDICAL  STUDENTS  AND  PHYSICIANS. 

Demi-Octavo.    Price  of  each  book,  Cloth,  $3.00;  Leather,  $3.50. 

The  object  held  in  view  in  the  preparation  of  this  Series  was  to  make  books  that  should  be  concise  and 
practical,  not  burdened  by  useless  theories  and  discussions,  but  containing  all  that  is  needed  or  necessary  for 
the  student  and  practitioner.  No  pains  have  been  spared  to  bring  them  up  to  the  times,  and  the  very  low 
])rice  at  which  they  have  been  published  is  an  additional  point  in  their  favor.  Full  circular,  descriptive  of 
tlie  Series,  will  be  sent  upon  application. 

WALSHAMS  PRACTICAL  SURGERY.  A  Manual  for  Students  and  Physicians.  By  W.M.  J. 
Walsh.am,  M.D.,  Asst.  Surgeon  to,  and  Demonstrator  of  Surgery  in,  St.  Bartholomew's  Hospital;  Sur- 
geon to  Metropolitan  Free  Hospital,  London,  etc.     236  Illust.     656  pp. 

Cloth,  $3.00 ;  Leather,  ^3.50 
From  the  Polyclinic. 

"  While  evidently  intended  to  be  a  text-book  for  students,  and  therefore  small  in  size  and  compactly  written,  is  neverthe- 
less full  enough  for  the  use  of  those  practitioners  who  desire  a  short  account  of  the  various  surgical  principles  and  operations 
involved  in  the  treatment  of  the  ordinary  run  of  surgical  cases.  The  author  seems  to  be  a  conservative  and  judicious  surgeon 
with  advanced  ideas. '' 

PARVIN'S-WINCKEL'S  DISEASES  OF  WOMEN.  Second  Edition.  A  Treatise  on  the  Dis- 
eases of  Women.  Including  the  Diseases  of  the  Bladder  and  Urethra.  By  Dr.  F.  Winckel,  Professor 
of  Gynaecology  and  Director  of  the  Royal  University  Clinic  for  Women,  in  Munich.  Revised  and  Edited 
by  Theophilus  Parvix,  m.d.,  Professor  of  Obstetrics  and  Diseases  of  Women  and  Children  in  Jeffer- 
son Medical  College.     Illustrated  by  150  fine  Engravings  on  Wood,  most  of  which  are  new.     760  pp. 

Cloth,  $3.00;  Leather,  $3.50 

GALABIN'S  MIDWIFERY,  A  Manual  of  Widwifery.  By  Ai  FRED  Lewis  Galabin,  m.a.,  m.d., 
Obstetric  Physician  and  Lecturer  on  Midwifery  and  the  Diseases  of  Women  at  Guy's  Hospital,  London; 
Examiner  in  Midwifery  to  the  Conjoint  Examining  Board  of  England.     227  Illustrations.     753  pages. 

Cloth,  $3.00;  Leather,  $3.50 

Front  the  Archivrs  of  Gyneecology,  New  York. 

"  The  illustrations  are  mostly  new  and  well  executed,  and  we  heartily  commend  this  book  as  far  superior  to  any  manual 

upon  this  subject." 

YEO'S  MANUAL  OF  PHYSIOLOGY.  Fourth  Edition.  A  New  Text-book  for  Students.  By 
Gerald  F.  Yeo,  m.d.,  f.r.c.s.,  Professor  of  Physiology  in  King's  College,  London.  321  Illustra- 
tions and  a  Glossary.     758  pages.  Cloth,  33.00;  Leather,  $3.50 

RICHTER'S  ORGANIC  CHEMISTRY.  By  Prof.  Victor  von  Richter,  University  of  Breslau. 
Authorized  translation.  First  American,  from  the  Fourth  German  Edition.  By  Edgar  F.  Smith,  m.d., 
PH.D.,  Translator  of  Richter's  Inorganic  Chemistry;  Prof,  of  Chemistry  in  Wittenberg  College,  .Spring- 
field, Ohio;  formerly  in  the  Laboratories  of  the  University  of  Pennsylvania;  Member  of  the  Chemical 
Societies  of  Berlin  and  Paris,  of  the  Academy  of  Natural  Sciences  of  Philadelphia,  etc.  Illustrated. 
710  pages.  Cloth,  $300;  Leather,  33-50 

GOODHARTAND  STARR,  DISEASES  OF  CHILDREN.  Second  Edition.  By  J.  F.Goidhart, 
M.D.,  Physician  to  the  Evelina  Hospital  for  Children;  Assistant  Physician  to  Guy's  Hospiial,  London. 
Sec  nd  American  from  third  English  Edition.  Revised  and  Edited  by  Louis  Starr,  m.d.,  Clinical 
Pro^'essor  of  Diseases  of  Children  in  the  Hospital  of  the  Univer.sity  of  Pennsylvania,  and  Physician  to  the 
Children's  Hospital,  Phila.  With  many  new  Prescriptions  and  Directions  for  making  Artificial  Human 
Milk,  for  the  Artificial  Dige.stion  of  Milk,  etc.     760  pages.  Cloth,  ;^3. 00;  Leather,  ^3.50 

From  The  New  York  Medical  Record. 

"  As  it  is  said  of  some  men,  so  it  might  be  said  of  some  books,  that  they  are  '  born  to  greatness.'     This  new  volume  ha.«, 

we  believe,  a  mission,  particularly  in  the  hands  of  the  young  members  of  the  profession.     In  these  days  of  prolixity  in  medical 

literature,  it  is  refreshing  to  meet  with  an  author  who  know>  both  what  to  say  and  when  he  has  said  it." 

WARING'S  PRACTICAL  THERAPEUTICS.  Fourth  Edition.  A  Manual  of  Practical  Thera- 
peutics, considered  with  reference  to  Articles  of  the  Materia  Medica.  Containing,  also,  an  Index  of 
Diseases,  with  a  list  of  Medicines  applicable  as  Remedies,  and  a  full  Index  of  the  Medicines  and 
Preparations  noticed  in  the  work.  By  Edward  John  Waring,  m.d.,  f.r.c.p.,  f.l.s.,  etc.  4th 
Edition.  Rewritten  and  Revised.  Edited  by  Dudley  W.  Buxton,  m.d  ,  Asst.  to  the  Prof,  of  Medicine 
at  University  College  Hospital;  Member  of  the  Royal  College  of  Physicians  of  London.     666  pages. 

Cloth,  $3.00;  Leather,  $3.50 

From  The  Kansas  Citv  Medical  Record. 

■'As  a  work  of  reference  it  excels,  on  account  of  the  several  complete  indexes  added  to  this  edition.     It  was  deservedly 

popular  in  former  editions,  and  will  be  more  so  in  the  one  before  us,  on  account  of  the  careful  arrangement  of  the  subjects." 

REESE'S  M  EDICAL  JURISPRUDENCE  AND  TOXICOLOGY.  Second  Edition.  By  John  J. 
Reese,  MD.,  Professor  of  Medical  Jurisprudence  and  Toxicology  in  the  University  of  Pennsvlvania  ;  late 
Presdent  of  the  Medical  Jurisprudence  Society  of  Philadelphia;  Physician  to  St.  Joseph's  Hospital; 
Member  of  the  Colleee  of  Physicians  of  Phila.;  Corresp  inding  Member  of  the  New  York  Medico  Le^al 
Society,  etc.     2d  Edition.     Revised  and  Enlarged.     654  pages.  Cloth,  $300;  Leather,  ;?3. 50 

THE  MOST  PRACTICAL  SERIES  OF  TEXT-BOOKS- 


JUST  PUBLISHED.     THIRD  EDITION. 

HUMAN  PHYSIOLOGY. 

By  LANDOIS  AND  STIRLING. 

With  692  Illustrations. 

THIRD    AMERICAN,   FROM    THE    SIXTH    GERMAN    EDITION. 

A  Text-Book  of  Human  Physiology,  including  Histology  and  Microscopical  Anatomy, 
with  special  reference  to  the  requirements  of  Practical  Medicine.  -  By 
Dr.  L.  Landois,  Professor  of  Physiology  and  Director  of  the  Physiological  Institute, 
University  of  Greifswald.  Translated  from  the  Fifth  German  Edition,  with  addi- 
tions by  Wm.  Stirling,  m.d.,  scd.,  Brackenbury,  Professor  of  Physiology  and 
Histology  in  Owen's  College  and  Victoria  University,  Manchester;  Examiner  in 
the  Honors'  School  of  Science,  University  of  Oxford,  England.  Third  Edition, 
revised  and  enlarged.  692  Illustrations. 
"A   BRIDGE    BETWEEN    PHYSIOLOGY   AND    PRACTICAL    MEDICINE." 

One  Volume.    Royal  Octavo.    Cloth,  $6.50 ;  Leather,  $7.50. 

From  the  Prefaces  to  the  English  Edition. 
The  fact  that  Prof.  Landois'  book  has  passed  through  four  large  editions  in  the  original  since  1880,  and 
that  in  barely  six  months'  time  a  second  edition  of  the  English  has  been  called  for,  shows  that  in  some 
special  way  it  has  met  a  want.  The  characteristic  which  has  thus  commended  the  work  will  be  found 
mainly  to  lie  in  its  eminent  practicability;  and  it  is  this  consideration  which  has  induced  me  to  undertake  the 
task  of  putting  it  into  English.  Landois'  work,  in  fact,  forms  a  Bridge  between  Physiology  and  the  Practice, 
of  Medicine.  It  never  loses  sight  of  the  fact  that  the  student  of  today  is  the  practicing  physician  of 
to-morrow.  In  the  same  way,  the  work  offers  to  the  busy  physician  in  practice  a  ready  means  of  refreshing 
his  memory  on  the  theoretical  aspects  of  Medicine.  He  can  pass  backward  from  the  examination  of  patho- 
logical phenomena  to  the  normal  processes,  and,  in  the  study  of  these,  find  new  indications  and  new  lights 
for  the  appreciation  and  treatment  of  the  cases  under  consideration.  With  this  object  in  view,  all  the 
methods  of  investigation  which  may,  to  advantage,  be  used  by  the  practitioner,  are  carefully  and  fully 
described.  Many  additions,  and  about  one  hundred  illustrations,  have  been  introduced  into  this  second 
English  edition,  and  the  whole  work  carefully  revised. 

PRESS  NOTICES. 

"  Most  effectivsly  aids  the  busy  physician  to  trace  from  morbid  phenomena  back  the  course  of  divergence  from 
healthy  physical  operations,  and  to  gather  in  this  way  new  lights  and  novel  indications  for  the  comprehension  and  treatment 
ot  the  maladies  with  which  he  is  called  upon  to  cope." — American  Journal  nf  Medical  Sciences. 

"  I  know  of  no  book  which  is  its  equal  in  the  applications  to  the  needs  of  clinical  medicine." — Pro/.  Harrison  Allen,  lati 
Professor  of  I'hysiology ,  University  of  Pennsylvania. 

"  We  have  no  hesitation  in  saying  that  this  is  the  work  to  which  the  Practitioner  will  turn  whenever  he  desires  light 
thrown  upon  the  phenomena  of  a  complicated  or  important  case." — Edinburgh  Medical  Journal. 

"  So  great  are  the  advantages  offered  by  Prof.  Landois'  '1'ext- Book,  from  the  exhaustive  and  eminently  practical 
manner  in  which  the  subject  is  treated,  that  it  has  passed  through  four  large  editions  in  the  same  number  of  years.  .  .  . 
Dr.  Stirling's  annotations  have  materially  added  to  the  value  of  the  work.  Admirably  adapted  for  the  Practitioner.  .  .  . 
With  this  Text-book  at  command,  no  Student  could  fail  in  his  examination." — The  Lancet. 

"One  of  the  most  practical  works  on  Physiology  ever  written,  forming  a  '  bridge  '  between  Physiology  and  Practical 
Medicine.  .  .  .  Its  chief  merits  are  its  completeness  and  conciseness.  .  .  .  The  additions  by  the  Editor  are  able  and  judicious. 
.  .  .  Excellently  clear,  attractive  and  succinct." — British  Medical  Journal. 

"The great  subjects  dealt  with  are  treated  in  an  admirably  clear,  terse,  and  happily  illustrated  manner." — Practitioner. 

"  Unquestionably  the  most  admirable  exposition  of  the  relations  of  Human  Physiology  to  Practical  Medicine  ever  laid 
before  English  readers  " — Students'  Journal. 

"  As  a  work  of  reference,  Landois  and  Stirling's  Treatise  ought  to  take  the  foremost  place  among  the  text- 
books in  the  English  language.     The  wood-cuts  are  noticeable  for  their  number  and  beauty." — Glnsgo^v  Medical  Journal. 

"  Landois'  Physiology  is,  without  question,  the  best  text-book  on  the  subject  that  has  ever  been  written." 
— New  York  Medical  Record.  , 

"■  The  chapter  on  the  Brain  and  Spinal  Cord  will  be  a  irost  valuable  one  for  the  general  reader,  the  translator's  notes  adding 
not  a  little  to  its  importance.  The  sections  on  Sight  and  Hearnig  are  exhaustive.  .  .  .  The  Chemistry  of  the  Urine  is  thoroughly 
considered.  ...  In  its  present  form,  the  value  of  the  original  has  been  greatly  increased.  .  .  .  The  text  is  smooth,  accurate, 
and  unusually  fiee  from  Germanisms  ;  in  fact,  it  is  good  English." — Neiu  York  Medical  Journal. 

"  It  is  not  for  the  physiological  student  alone  that  Prof.  Landois'  book  possesses  great  value,  for  it  has  been  addressed 
TO  THE  practitioner  OF  MEDICINE  as  well,  who  will  find  here  a  direct  application  of  physiological  to  pathological  processes." 
Medical  Bulletin. 

P.  BLAKISTON,  SON  &  CO.,  Publishers,  1012  Walnut  St.,  Philadelphia. 


JUST  READY.     A  TEXT-BOOK  OF 

DISEASES  OF  THE  EYE. 

BY  DR.  EDOUARD  MEYER, 

ProJ.  ,i  V&cole  Pratique  de  la  Faculte  de  Medecine  de  Paris;    Chevalier  of  the  Legion  of  Honor,  etc, 

AUTHORIZED    TRANSLATION   BY 

FREELAND  FERGUS,  M.  B.,  Assistant  Surgeon,  Glasgow  Eye  Infirmary. 

COLORED   PLATES   PRINTED   UNDER   THE    DIRECTION   OF 

DR.   RICHARD  LIEBREICH,  M.  R.  C.  S.,  Author  of  the  "Atlas  of  Ophthalmoscopy." 

WITH  COLORED  PLATES  AND  267  ENGRAVINGS  ON  WOOD. 

Octavo.     650  Pages.     Cloth,  $4.50  ;    Leather,  $5.50. 

Synopsis  of  Contents. — Diagnosis  and  Treatment  of  Ocular  Affections.  Diseases  of  the  Conjunc- 
tiva.  Diseases  of  the  Cornea  and  Sclerotic.  Iris — Ciliary  Body — Choroid.  Glaucoma.  Diseases  of  the 
Optic  Nerve  and  Retina.  Amblyopia  and  Amaurosis.  Diseases  of  the  Vitreous  Body.  Diseases  of  the 
Crystalline  Lens.  Refraction  and  Accommodation.  The  Muscles  of  the  Eye.  Diseases  of  the  Eyelids. 
Diseases  of  the  Lachrymal  Passages.      Diseases  of  the  Orbit.     Table  of  Dioptries.     Index. 


Forming  a  complete  systematic  Manual  of  Ophthalmology.     The  translating 

and  editing  have  been  done  with  the  assistance 
l^x^  of  the  author.     The  illustrations,  which  will  be 

W^  found  of  great  help  in  diagnosis,  have  been  care- 
fully engraved ;  the  colored  plates,  being  re- 
duced from  Liebreich's  Atlas  of  Ophthalmology 
and  printed  under  the  direction  of  Di.  Liebreich, 
are  accurate  and  faithful  representations  of  their 
subjects. 

Treatment  and  Diagnosis  receive  full  share 

Fig.  27.-pTTryqium.  of  attention.       Refraction    and   accommodation 

(Attention  is  called  to  the  help  in  diagnosis  of  a    occupy  a   section    of   ovcr  sixty    pagcs,  being 

cut  of  this  character.    It  is  followed  by  three  en-    handled    in   a  practical,   concisc    way    that  will 

gravings  showing  the  operation  for  Pterygium.)  ,     •  i /-  •     11  1  1        1  • 

commend  itself  specially  to  students  and  physi- 
cians who  have  given  the  subject  but  little  attention.  The  chapters  describing  the 
subject  of  general  diagnosis  and  the  proper  instruments  to  be  used,  are  thorough 
and  well  illustrated. 

Dr.  Swan  M.  Burnett,  reviewing  the  book  in  The  Archives  0/  Ophthabnology^  says  :    "  The  cause  of  its  popularity  is  not 
fiar  to  seek.     It  is  clear,  concise,  conservative  and  eminently  practical." 

This  book  has  gone  through  three  French  and  four  German  Editions, 
has  been  translated  into  Italian,  Spanish,  Polish,  Russian,  Japanese — 
this,  the  English  Edition,  making  the  eighth  language  in  which  it  has 
been  published. 


JUST    READY. 


THE    SEVENTH    REVISED   AND    ENLARGED    EDITION 

OF 

ROBERTS'  PRACTICE. 


THE  THEORY  AND  PRACTICE  OF  MEDICINE.  By  Fred. 
T.  Roberts,  m.d.,  f.r.c.p.,  Professor  of  Materia  Medica  and  Therapeu- 
tics at  University  Hospital,  Physician  to  Unive~s-.*v  College  Hospital,  etc. 
Seventh  Edition.  Revised  and  Enlarged.  One  vo.jme,  8vo.,  with  nu- 
merous Illustrations.  Cloth  Binding,  ;^5.5o;  Leather,  ;^6.5o 

The  present  edition  has  been  fully  revised  throughout,  and  in  some  parts  rewritten  or  re- 
arranged. While  an  endeavor  has  been  made  to  bring  every  subject  up  to  date  in  all  its  aspects, 
special  attention  has  been  given  to  the  questions  of  treatment,  with  the  view  of  bringing  into 
notice  important  therapeutic  agents  or  methods  which  have  been  recently  introduced. 

The  unexceptional  large  and  rapid  sale  of  this  book,  and  the  universal  commendation  it  has 
received  from  the  profession,  seems  to  be  a  sufficient  guarantee  of  its  merit  as  a  Text-book.  The 
publishers  are  in  receipt  of  numerous  letters  from  professors  in  the  medical  schools,  speaking 
favorably  of  it,  and  below  they  give  a  few  extracts  from  the  medical  press,  American  and 
English,  attesting  its  superiority  and  value  to  both  student  and  practitioner.  The  present  edi- 
tion has  been  thoroughly  revised  and  much  of  it  re- written. 

"  The  best  Text-book  for  students  in  the  English  language.  We  know  of  no  work  in  the 
English  language,  or  in  any  other,  which  competes  with  this  one." — Edinburgh  Medical  Journal. 

"  Dr.  Roberts'  book  is  admirably  fitted  to  supply  the  want  of  a  good  Handbook,  so  much 
felt  by  every  medical  student." — Student' s  Journal  and  Hospital  Gazette. 

"^'i  here  are  great  excellencies  in  this  book,  which  will  make  it  a  favorite  with  the  student." 
— Richmond  and  Louisville  Journal. 

"  We  heartily  recommend  it  to  students,  teachers,  and  practitioners." — Boston  Medical  and 
Surgical  Joitrnal. 

"  It  is  unsurpassed  by  any  work  that  has  fallen  into  our  hands  as  a  compendium  for  students." 
The  Clinic. 

"  We  particularly  commend  it  to  students  about  to  enter  upon  the  practice  of  their  profession." 
— St.  Loziis  Medical  and  Surgical  Journal. 

"  If  there  is  a  book  in  the  whole  of  medical  literature  in  which  so  much  is  said  in  so  few 
words,  it  has  never  come  within  our  reach." — Chicago  Aledical  Journal. 


BY  THE  SAME  AUTHOR. 
NOTES   ON  MATERIA  MEDICA  AND  PHARMACY. 

ESPECIALLY    ARRANGED    FOR    THE    USE    OF    STUDENTS. 

16mo,  Cloth,  $2.00. 


For  sale  by  all  Booksellers  ;  or  will  be  sent  by  mail,  postpaid,  on  receipt  of  price 
by  the  Publishers, 

P.  Blakiston,  Son  &  Co.,  1012  Walnut  Street,  Philadelphia. 


"IT  STANDS  WITHOUT  AN  EQUAL  AS  THE  MOST  COMPLETE  WORK  ON  PRACTICE  IN 
THE  ENGLISH  LANGUAGE."— A'ct**  Vork  Medical  Journal. 

FAGGE'S  PRACTICE  OF  MEDICINE, 

Two  Large  Royal  Octavo  Volumes.     Containing  over  1900  Pages. 
PRICE,  HANDSOMELY   BOUND   IN  CLOTH,  S8.00. 

The  Principles  and  Practice  of  Medicine. 

Bv  CHARLES  HILTON  FAGGE,  M.D.,  F.R.C.P..  F.R.M.C.S., 

Examiner  in  Medicine,  University  of  London  ;  Physician  to,  and  Lecturer  on  Pathology  in,  Guy  s  Hospital; 
Senior  Physician  to  Evelina  Hospital  for  Sick  Children,  etc. 

EDITED   AND   ARRANGED    FOR   THE   PRESS 

By  p.  H.  Pye-Smith,  M.D.,  F.R.C.P., 

Lecturer  on  Medicine  in  Guy's  Hospital,  London,  etc., 

WITH  A  SECTION  ON  CUTANEOUS  AFFECTIONS,  BY  THE  EDITOR,  A  CHAPTER  ON  CAR- 
DIAC DISEASES,  BY  SaMUEL  WiLKES,  M.  D.,  F.  R.  S.,  AND  TWO  INDEXES,  ONE  OF 
AUTHORS  AND   ONE   OF   SUBJECTS,  BY   ROBERT   EdMUND   CaRRINGTON. 

Two  Volumes.  Royal  Octavo.  1900  Pages. 

Price  in  Cloth,  $8.00.     Full  Leather,  $10.00.     Half  Morocco,  $12.00.    Half  Eussia,  $12.00. 


It  is  based  on  laborious  researches  into  the  pathological  and  clinical  records  of 
Guy's  Hospital,  London,  during  the  twenty  years  in  which  the  author  has  held  office 
there  as  Medical  Registrar,  as  Pathologist,  and  as  Physician.  Familiar  beyond  most, 
if  not  all,  of  his  contemporaries,  with  modern  medical  literature,  a  diliger/.  reader  of 
French  and  German  periodicals.  Dr.  Fagge,  with  his  remarkably  retentive  memory  and 
methodical  habits,  was  able  to  bring  to  his  work  of  collection  and  criticism  almost 
unequaled  opportunities  of  extensive  experience  in  the  wards  and  dead  house.  The 
result  is  that  which  will  probably  be  admitted  to  be  a  fuller,  more  original,  and  more 
elaborate  text-book  on  medicine  than  has  yet  appeared.  It  is  the  first  of  importance 
emanating  from  Guy's  Hospital,  and  the  only  two-volume  work  on  the  Practice  of 
Medicine  that  has  been  issued  for  a  number  of  years.  Several  subjects,  such  as 
Syphilis,  that  are  usually  omitted  or  but  slightly  spoken  of  in  a  general  work  of  this 
character,  receive  full  attention. 

Dr.  Walter  Moxon,  one  of  Dr.  Fagge's  contemporaries,  and  a  great  personal 
friend,  writes  of  him,  in  a  recent  number  of  the  London  Lancet : — 

"  Fagge  was,  to  my  mind,  the  type  of  true  medical  greatness.  I  believe  he  was  capable  of  any  kind  of 
excellence.  His  greatness  as  a  physician  became  evident  lo  observers  of  character  very  soon  after  his  brilliant 
student  career  had  placed  him  on  the  staff  of  Guy's  Hospital:  he  did  not  merely  group  already  known  facts, 
but  he  found  new  facts.  Former  volumes  of  Guy's  Hospital  Reports  contain  ample  and  most  valuable  proof  of 
his  greatness  as  a  physician.  His  power  of  observation  was  sustained  by  immense  memory,  and  brought  into 
action  by  vivid  and  constant  suggestiveness  of  intelligence.  He  was  a  physician  by  grace  of  nature,  and  being 
gifted  with  a  quickness  of  perception,  a  genius  for  clinical  facts  and  a  patience  in  observation,  he  was  at  once 
recognized  as  a  successful  practitioner  and  a  leading  figure  in  the  hospital  and  among  the  profession. 


NEW  AND  REVISED  EDITIONS. 

?  OUIZ-COMPENDS  ? 

A  SERIES  OF  PRACTICAL  MANUALS  FOR  THE  PHYSICIAN  AND   STUDENT. 

Compiled  in  accordance  with  the  latest  teachings  of  prominent  lecturers  and  the 

most  popular  Text-books. 

They  form  a  most  complete,  practical  and  exhaustive  set  of  manuals,  containing  information 
nowhere  else  collected  in  such  a  condensed,  practical  shape.  Thoroughly  up  to  the  times  in 
csz'.j  respect,  containing  many  new  prescriptions  and  formula,  and  over  two  hundred  and  thirty 
illustrations,  many  of  which  have  been  drawn  and  engraved  specially  for  this  series.  The 
authors  have  had  large  experience  as  quiz-masters  and  attaches  of  colleges,  with  exceptional 
opportunities  for  notmg  the  most  recent  advances  and  methods.  The  arrangement  of  the  suli- 
jects,  illustrations,  types,  etc.,  are  all  of  the  most  approved  form,  and  the  size  of  the  books  is 
such  that  they  may  be  easily  carried  in  the  pocket.  They  are  constantly  being  revised,  so  as  to 
include  the  latest  and  best  teachings,  and  can  be  used  by  students  of  any  college  of  medicine, 
dentistry  or  pharmacy. 

Bound  in  Cloth,  each  $i.oo.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 

No.  I.  Human  Anatomy.  Fourth  Edition,  including  Viscer.-\1  Anatomy,  formerly 
published  separately.  Over  100  Illustrations.  By  Samuel  O.  L.  Potter,  m.a.,  m.d  , 
late  A.  A.  Surgeon  U.  S.  Army.    Professor  of  Practice,  Cooper  Med.  College,  San  Francisco. 

Nos.  2  and  3.  Practice  of  Medicine.  Fourth  Edition.  By  Daniel  E.  Hughes,  m.d., 
Demonstrator  of  Clinical  Medicine  in  Jefferson  Med.  College,  Phila.     In  two  parts. 

Part  I. — Continued,  Eruptive  and  Periodical  Fevers,  Diseases  of  the  Stomach,  Intestines,  Peritoneum, 
Biliary  Passages,  Liver,  Kidneys,  etc.  (including  Tests  lor  Urine),  General  Diseases,  etc. 

Part  II. — Diseases  of  the  Respiratory  System  (including  Physical  Diagnosis),  Circulatory  System  and  Ner- 
vous System  ;  Diseases  of  the  Blood,  etc. 

*-if*  These  little  books  can  be  regarded  as  a  full  set  of  notes  upon  the  Practice  of  Medicine,  containing  the 
Synonyms,  Definitions,  Causes,  Symptoms,  Prognosis,  Diagnosis,  Treatment,  etc.,  of  each  disease,  and  includmg 
a  number  of  prescriptions  hitherto  unpublished. 

No.  4.  Physiology,  including  Embryology.  Fifth  Edition.  By  Albert  P.  Brubaker, 
M.D.,  Prof,  of  Physiology.  Peiin'a  College  of  Dental  Surgery  :  Demonstrator  of  Physiology 
in  Jefferson  Med.  College,  Phila.     Revised,  Enlarged  and  Illustrated. 

No.  5.  Obstetrics.  Illustrated.  Fourth  Edition.  For  Physicians  and  Students.  By 
Henry  G.  Landis,  m.d.,  Prof,  of  Obstetrics  and  Diseases  of  Women,  in  Starling  Medical 
College,  Columbus.     Revised  Edition.     New  Illustrations. 

No.  6.     Materia   Medica,  Therapeutics   and   Prescription  Writing.     Fifth    Revised 

Edition.  With  especial  Relcrcnce  to  the  Physiological  Action  of  Diugs,  and  a  complete 
article  on  Prescription  Writing.  Based  on  the  Last  Revision  (Sixth)  of  the  U.  S.  Pharma- 
copoeia, and  including  many  ur.ofticiiial  remedies.  By  Samuel  ().  L.  Potter,  m.a.,  m.d., 
late  A.  A.  Surg.  U.  S.  Army ;  Prof,  of  Practice,  Cooper  Med.  College,  San  Francisco.  5th 
Edition.     Improved  and  Enlarged,  with  Index. 

No.  7.  Gynaecology.  A  Compend  of  Diseases  of  Women.  By  He.vry  Morris,  m.d., 
Demonstrator  of  Obstetrics,  Jefferson  Medical  0>llege,  Philadelphia.  In  Press. 

No.  8.  Diseases  of  the  Eye  and  Refraction,  including  Treatment  and  Surgery.  By  L. 
Webster  Fox,  m.d.,  Chief  Clinical  Assistant  Opthalmological  Dept.,  Jefferson  Medical 
College,  etc.,  and  Geo.  M.  Gould,  a.b.     71  Illustrations,  39  Formuliie.      2d  Edition. 

No.  9.  Surgery.  Illustrated.  Third  Edition.  Including  Fractures,  Wounds,  Disloca- 
tions, Sprains,  Amputations  and  other  operations;  Inflammation,  Suppuration,  Ulcers, 
Syphdis,  Tumors,  Shock,  etc.  Diseases  of  the  Spine,  Ear,  Bladder,  Testicles,  Anus,  and 
other  Surgical  Diseases.  By  Orville  Horwitz,  a.m.,  m.d..  Demonstrator  of  Surgery, 
Jcfierson  Medical  College.  Third  Edition.  Revised  and  Enlarged.  77  Formula;  and  91 
lllustraiions. 

No.  10.  Chemistry.  Inorganic  and  Organic.  For  Medical  and  Dental  Students.  By  Henry 
Leffmann.  m.d.,  Prof,  of  Chemistry  in  Penn'a  College  of  Dental  Surgery,  Phila.    2d  Ed. 

No.  II.      Fnarmacy.      Based   upon    "  Remington's    Text  Book  of   Pharmacy."      By  F.   E. 
St''WART,  m.d.,  ph.g.,  Quiz-Master  at  Philadelphia  College  of  Pharmacy.     Secon 

Bound  in  Cloth,  each  $1.00.     Interleaved,  for  the  Addition  of  Notes,  $1.25. 

8^"  These  books  are  constantly  revised  to  keep  up  with  the  latest  teachings  and  discoveries-. 


PUBLISHED   ANNUALLY. 


1890. 


NOW  READY.     39th  YEAR. 


f  HE  PHYSICIAN'S  YlSlTlNG  J  ^IST. 


(LINDSAY  &  BLAKISTON'S.) 

CONTENTS. 


AuMANAC  for  1890  and  1891, 

Table  op  Sic.ns  to  be  used  in  keeping  accounts. 

Marshall  Hall's  Rkauy  Method  in  Asphyxia. 

Poisons  and  Astidotks,  revised  for  1890. 

The  Metric  ok  Krench  Decimal  System  of 
Weights  and  Measures. 

Dose  Table,  revised  and  rewritten  for  1890,  by  He 
BART  Amory  Hare,  m  d  ,  Demonstrator  of  Thera- 
peutics, University  of  Pennsylvania. 

List  of  New   Remedies  for  1890,  by  same  autlior. 

Aids  TO  Diagnosis  and  Treatment  of  Diseases  op 
the  Eye,  Dr.  L.  Webster  Fox,  Clinical  Asst.  Eye 
Depi  ,  Jefferson  Medical  College  Hospital,  and  G. 
M.  Gould,  m.d. 

Diagram  Showing  Eruption  of  Milk  Teeth,  Dr. 
Louis  Starr,  Prof  of  Diseases  of  Children,  Univer- 
sity Hospital,  Philadelphia. 


PosoLOGicAL  Table,  Meadows. 

Disinfectants  and  Disinfecting. 

ExaminatI">n  op  Urine,  Dr.  J.  V alahv.  iaseii  u/on 
Tyson's  "  Practical  Examination  of  Urine."  6ih 
Edition. 

Incompatibility,  Dr.  S.  O.  L.  Potter. 

A  New  Complete  Table  for  Calculating  thb 
Period  of  Utero-Gestation. 

Syi.ve-ster's  Method  for  Artificial  Respiration. 
Illustrated. 

Diagram  of  the  Chest. 

Blank  Leaves,  suitably  ruled,  for  Visiting  Lists, 
Monthly  Memoranda,  Addresses  of  Patients  and 
others  ;  Adilresses  of  Nurses,  their  references,  etc. ; 
Accounts  asked  for;  Memoranda  of  Wants  ;  Obstet- 
ric and  Vaccination  Engagements;  Record  of  Births 
and  Deaths  ;  Cash  Account,  etc. 


REGULAR   EDITION. 


For  25  Patients  weekly. 
50 

75 

TOO  "  " 

50 


For  25  Patients  weekly. 
50 


2  Vols. 
2  Vols. 


J  Jan.  to  June] 
'^    ;.j 


July  to  Dec. 
Jan.  to  June 
July  to  Dec. 


Tucks,  pockets  and  Pencil,  |l.oo 

1.25 

1.50 

"  "  "  2.00 

"  "  "  2.50 


INTERLEAVED  EDITION. 

Interleaved,  tucks  and  Pencil, 


50 


2  Vols. 


I  Jan.  to  June  ] 
(  July  to  Dec.  J 


3.00 


1.25 
1.50 

3.00 


PERPETUAL  EDITION,  without  Dates. 
No.  1.     Containing  space  for  over  1300  names,  with  blank  page  opposite  each 

Visiting  List  page.  Bound  in  Red  Leather  cover,  with  pocket  and  Pencil,  $1.25 
No.  2.     Containing  space   for   2600  names,  with  blank   page  opposite   each 

Visiting  List  page.     Bound  like  No.  i,  with  Pocket  and  Pencil,     ....     1.50 

MONTHLY  EDITION,  without  Dates. 

No.  1.     Bound  without  Flap  or  Pencil 75 

No.  2,         "      with  Tucks,  Pencil,  etc i.oo 

These  lists,  without  dates,  can  be  commenced  at  any  time,  and  used  until  full, 
and  are  particularly  useful  to  young  physicians  unable  to  estimate  the  number  of 
patients  they  may  have  during  the  first  years  of  Practice,  and  to  physicians  in  locali- 
ties where  epidemics  occur  frequently.  In  the  Monthly  Edition  the  patient's  name 
has  to  be  entered  but  once  each  month. 

"  For  completeness,  compactness,  and  simplicity  of  arrangement  it  is  excelled  by  none  in  the  market." — ..V.  y 
Medical  Record. 

"The  book  is  convenient  in  form,  not  too  bulky,  and  in  every  respect  the  very  best  Visiting  List  published.' 
—  Canada  Medical  und  Surgical  Journal. 

"  After  all  the  trials  made,  there  are  none  superior  to  it." — Gaillard's  Medical  Journal. 

"  The  most  popular  Visiting  List  extant." — Bujjfalo  Medical  and  Surgical  Journal. 

"  We  have  used  it  for  years,  and  do  not  hesitate  to  pronounce  it  equal,  if  not  superior,  to  any." — Southern 
Clinic. 

This  is  not  a  complicated  system  of  keeping  accounts,  but  a  plain,  systematic 
record  which,  with  the  least  expenditure  of  time  and  trouble,  keeps  an  accurate  and 
concise  list  of  daily  visits,  engagements,  etc. 


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